Failure to Provide Ordered Adaptive Eating Equipment and Follow Speech Therapy Recommendations
Penalty
Summary
Staff failed to provide a resident with the required adaptive eating and drinking equipment as ordered by the physician and recommended by the speech therapist. The resident, who had hemiplegia following a stroke and was on a mechanically altered diet, was supposed to receive a two-handled spout cup, maroon spoon, inner lip plate, and scoop bowl, with explicit instructions for no straws to be used. Despite these orders and care plan directives, observations revealed that the resident was given a Styrofoam cup with a lid and straw, and only one two-handled cup with a spout lid, instead of the two spout cups required. The meal ticket also indicated no straws and two spout cups, but this was not followed. Interviews with staff confirmed the discrepancies, with a nurse aide acknowledging the incorrect equipment on the tray and an LPN unsure about the correct cup to provide. The speech therapist reiterated that the resident should only have two-handled cups with spout lids and no straws, both at meals and bedside, due to the resident's impulsive behaviors and increased aspiration risk. The facility's policy required adaptive equipment to be provided as determined by the therapist and ordered by the provider, but this was not consistently implemented for this resident.