Failure to Provide Ordered Assistive Eating Device During Meals
Summary
Facility staff failed to provide a divided plate as ordered for a resident during meals. The resident, who was severely cognitively impaired as indicated by a BIMS score of 3 out of 15, had a physician's order for a divided/sectional plate at all meals to decrease spillage and increase oral intake. Observations on two separate occasions showed the resident was served meals without the required divided plate, instead receiving food in separate bowls or on a regular plate. The care plan for the resident, which addressed nutritional risks related to chronic disease, cognitive impairment, and GERD, did not document the use of assistive devices during meals. Interviews with staff revealed a lack of awareness and recall regarding the use of the divided plate for the resident. The LPN supervising the resident during meals did not remember the resident using a divided plate, and the speech language pathologist who recommended the device had not worked with the resident since the previous year. Facility policy required that adaptive devices be provided for residents who need them and that assistance be given to ensure residents can use and benefit from such equipment. Despite these requirements and documented orders, the assistive device was not consistently provided.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with renal failure and legal blindness, who required set-up assistance for meals, had physician orders for a renal diet with specific food restrictions and the use of a blue scoop bowl and plate guard. During multiple observed meals, the tray line provided only a plate guard and no scoop bowl, despite the meal ticket indicating the need for both. Dietary staff reported that previously available scoop bowls could no longer be found anywhere in the facility, resulting in the resident not receiving the ordered adaptive equipment during the observed meal services.
A resident with cerebral palsy, dysphagia, severe cognitive impairment, and total dependence on staff for eating had a physician order for a coated spoon with all meals. Review of documentation showed the coated spoon was not provided for a substantial number of meals, and direct observation found that a plastic disposable spoon was used despite the tray ticket specifying a coated spoon. A CNA confirmed the coated spoon was frequently omitted and noted the resident sometimes bites down on the spoon, making the coated utensil beneficial. The facility’s administration acknowledged that prescribed adaptive equipment was not consistently provided or used as ordered.
Surveyors found that the facility did not provide adequate and appropriate eating utensils with resident meal trays. Observations showed meal trays being passed with only a spoon, sometimes plastic, and no additional utensils or napkins, with brown paper towels substituted instead. Dietary staff reported an ongoing shortage of metal silverware, napkins, and sometimes juice cups, and stated that plastic utensils were used for about half of all trays over several months. Several cognitively intact residents on various diets, some needing set-up assistance and others independent with eating, reported frequently receiving only a spoon, receiving plastic utensils for many meals, or occasionally receiving no utensils at all, and these reports were confirmed by concurrent observation of their lunch trays. Facility policy required that meals be served using reusable dishes and flatware, and administration acknowledged residents should receive appropriate silverware for all meals.
A resident with hemiplegia and hemiparesis, moderate cognitive impairment, and documented nutrition/hydration risk had a physician order and care plan specifying use of a spouted cup with handle at all meals, but was repeatedly served beverages in regular cups with lids and straws. Observations showed that staff delivering meal trays did not properly check diet slips against tray contents, and one NA admitted she did not verify accuracy and would leave incorrect trays as they were, despite training. The resident reported spilling drinks with regular cups and finding the spouted cup easier to use, while the DON and Dietary Manager confirmed that staff were expected to verify trays and that appropriate adaptive cups were available in stock.
A resident with a history of stroke and difficulty eating was not consistently provided with physician-ordered built-up utensils at mealtimes, despite clear documentation and facility policy. The resident often had to request the adaptive equipment from staff, resulting in delays and cold food, as observed and confirmed by staff interviews.
A resident with encephalopathy and an order for a Kennedy Cup was repeatedly observed drinking from a regular cup with a straw instead of the prescribed assistive device. Staff interviews confirmed knowledge of the resident not using the Kennedy Cup as ordered, and the care plan documented the need for meal assistance due to intellectual disability.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered adaptive eating equipment for a resident who required it. The resident was admitted with diagnoses including hypertensive urgency, renal dialysis, glaucoma, and legal blindness. A quarterly MDS assessment documented that the resident was independent in daily decision making but required set-up assistance for meals. Physician orders specified a renal diet with regular texture and thin liquids, double protein, several food restrictions, an 1800 milliliter fluid restriction, and the use of a blue scoop bowl and plate guard related to renal failure. During a supper meal observation, the resident’s meal ticket indicated the need for both a blue scoop bowl and a plate guard, but the tray was prepared with only a plate guard. Further observations of subsequent meal tray lines showed that the required scoop bowl continued to be unavailable for the resident’s meals. At one lunch service, staff confirmed there were no scoop bowls available for the resident’s tray, despite the order specifying their use. Dietary staff interviews revealed that the facility previously had multiple scoop bowls but they could no longer locate them, and that only three had recently been available before they also went missing. Multiple staff, including dietary aides and the dietary manager, reported they were unable to find any scoop bowls in the kitchen, resident rooms, or on the units at the time of the observations. As a result, the resident did not receive the ordered adaptive equipment during the observed meals.
Failure to Consistently Provide Prescribed Adaptive Dining Equipment
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide prescribed adaptive dining equipment for a resident with significant cognitive and physical impairments. The resident had diagnoses including cerebral palsy and dysphagia and was documented on a quarterly MDS as being rarely or never understood, having short- and long-term memory problems, being severely cognitively impaired for decision making, and dependent on staff for eating. A physician order dated April 4, 2024, required the use of a coated spoon with all meals. However, review of the resident’s January Task Documentation Report for January 1 through January 28, 2026, showed that the coated spoon was not provided for 31 out of 84 meals served. During a lunch observation on January 29, 2026, the resident’s tray ticket indicated a coated spoon, but a plastic disposable spoon was placed on the tray instead. A nurse aide confirmed at that time that the coated spoon was not provided and further stated that the coated spoon was frequently not included on the resident’s tray. The nurse aide also reported that the resident sometimes bites down on the spoon while being fed and that the coated spoon is beneficial for the resident. The Nursing Home Administrator acknowledged that the facility failed to ensure the prescribed adaptive equipment (coated spoon) was consistently provided and used in accordance with the physician’s orders, in violation of 28 Pa. Code 211.12(d)(3)(5) related to nursing services.
Failure to Provide Adequate and Appropriate Eating Utensils for Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate eating utensils and special eating equipment to residents during meals, as required by facility policy. Surveyor observations on the morning of 01/22/26 showed CNAs passing breakfast trays that contained only a metal spoon, with no additional silverware or utensils present or offered. Later that morning, a dietary aide was observed transporting 15–20 meal trays on an open cart, each tray containing only a plastic spoon placed on a folded brown paper towel next to the covered plate. Interviews with dietary staff revealed there was an ongoing shortage of metal silverware, resulting in plastic utensils being used for at least half of the residents’ trays for each meal. Staff also reported the kitchen had been out of napkins since 01/20/26 and was using folded brown paper towels from a hand towel dispenser instead, and that the facility sometimes ran out of juice cups. One dietary aide stated there had been a shortage of silverware and utensils for at least six months. Review of the facility’s policy titled "Use of Disposable Dishes/Flatware" indicated that resident meals were to be served using reusable dishes and flatware. Multiple residents with varying diagnoses and functional statuses reported and demonstrated that they frequently did not receive appropriate utensils with their meals. Cognitively intact residents on regular, mechanical soft, carbohydrate-controlled, or no concentrated sweets diets, some requiring set-up assistance and others independent with eating, stated they often received only a spoon, sometimes plastic utensils, and at times no utensils at all. Examples included residents reporting receiving only a spoon to eat meat or salad, receiving plastic utensils for about half of their meals, and occasionally having to eat with their fingers. During each of these interviews at lunchtime on 01/22/26, observations confirmed that the residents’ trays contained only a metal spoon. The administrator later confirmed that residents should receive appropriate silverware for all meals, consistent with facility policy. This deficiency represents non-compliance investigated under Complaint Number 2693876.
Failure to Provide Ordered Adaptive Drinking Equipment and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed adaptive drinking equipment and to ensure staff verified diet slips against meal trays. A resident with hemiplegia and hemiparesis following a nontraumatic intracranial hemorrhage had a physician’s order, dated 7/31/25, for a spouted cup with handle with all meals. The resident’s care plan, last reviewed 9/25/25, identified nutrition/hydration risk and included an approach to provide adaptive equipment with meal trays as ordered, specifically a spouted cup with handle. The quarterly MDS documented moderate cognitive impairment, impairment of one upper and one lower extremity, and independence with eating after tray setup. On observation, the breakfast tray diet slip specified a spouted cup with handle, but the tray contained only regular cups with lids and straws, and the beverages appeared untouched. Later observation of the lunch meal showed a nurse aide delivering the tray, placing it on the overbed table, removing the plate lid, and attempting to leave without checking the diet slip. When questioned, the aide initially stated she had not checked the diet slip and that they “didn’t really say anything,” then, after looking, failed to notice the spouted cup order and incorrectly stated the resident was not supposed to have one before correcting herself. She acknowledged that when a tray does not match the diet slip, she “just leaves it and hopes for the best,” despite having been trained on tray passing at hire. The resident reported sometimes spilling drinks when using a regular cup with lid and straw and that the spouted cup with handle was easier to use. The DON stated that staff passing trays were responsible for checking diet slips and returning incorrect trays to Dietary, and the Dietary Manager reported that multiple staff checked trays before carting and that there was adequate stock of spouted cups, yet the resident still received breakfast and lunch without the ordered assistive device.
Failure to Provide Required Feeding Adaptive Equipment at Meals
Penalty
Summary
Staff failed to provide a resident with the required feeding adaptive equipment at each meal, despite a physician's order and clear documentation on the resident's meal card indicating the need for built-up utensils. The resident, who had a history of stroke and significant difficulty eating without adaptive equipment, reported that the specialized utensils were usually missing from her meal tray. On multiple observed occasions, the resident's tray was delivered without the necessary adaptive device, and she had to request assistance from a CNA to obtain it, resulting in her food becoming cold before she could eat. Review of facility policy confirmed that residents should be assessed for adaptive equipment and provided with it as needed to facilitate independence. Interviews with the Dietary Manager and Administrator confirmed that there were sufficient devices available and that staff were expected to provide them when ordered by a physician. However, observations and interviews demonstrated that the process was not consistently followed, leading to the resident not receiving the required adaptive equipment at mealtimes.
Failure to Provide Prescribed Assistive Drinking Device
Penalty
Summary
A deficiency was identified when a resident with a medical diagnosis of encephalopathy and an order for a regular diet with a Kennedy Cup, built-up fork, and spoon was not provided with the prescribed assistive drinking device. The resident's physician order, dated May 21, 2025, specified the use of a Kennedy Cup, which is a spill-proof cup with a secure lid and J-shaped handle, to assist with drinking. Observations conducted over three consecutive lunch services revealed that the resident was instead drinking from a regular cup with a straw, contrary to the physician's order. Interviews with facility staff, including the unit manager RN, confirmed awareness that the resident was not using the Kennedy Cup as ordered. The Nursing Home Administrator and Director of Nursing were not aware of the resident's lack of access to the prescribed assistive device until the issue was presented to them. The resident's care plan indicated a need for assistance with meals due to intellectual disability and a stable weight, further supporting the necessity for the assistive device. The failure to provide the required Kennedy Cup constituted noncompliance with regulations regarding assistive devices for eating and drinking.
Plan Of Correction
The facility cannot retroactively correct this issue. Resident 7 was given a Kennedy cup for all meals. DON/Designee conducted a facility-wide audit of residents who have orders for adaptive equipment to ensure appropriate adaptive equipment was in place during meals. DON/Designee educated Nursing/Dietary staff on the importance of assuring that assistive devices ordered are in place during meals. DON/Designee will conduct meal observations weekly x 4 then monthly x 3 or until compliance is achieved to verify adaptive equipment ordered is present during meals. Results will be discussed at the monthly QAPI.
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