Failure to Provide Required Transfer and Eating Assistance to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent for activities of daily living following right leg surgery and had significant vision loss, was not provided with the required assistance for transfers and eating. Despite an active physician's order and care plan interventions specifying that the resident should be out of bed for all meals and required two staff for transfers and repositioning, staff consistently failed to get the resident out of bed for meals. Observations and interviews confirmed that the resident remained in bed for all meals and was not routinely asked if she wanted to get out of bed, contrary to her care plan and physician's orders. Additionally, the resident, who was dependent for feeding, reported that not all staff stayed to assist her with meals, and staff interviews revealed a lack of awareness regarding her need for feeding assistance and transfer out of bed for meals. Documentation was inconsistent or missing for care provided, and staff were unclear about the resident's care requirements. The resident experienced significant weight loss since admission, and dietary documentation noted the need for meal assistance to ensure adequacy. The failure to provide necessary services for eating and transfer assistance constituted a deficiency in care for a dependent resident.