Failure to Serve Meals in a Dignified and Timely Manner
Penalty
Summary
The facility failed to provide care and services in a dignified manner by not serving meals to all residents in the dining area at the same time, specifically affecting three residents with severe cognitive impairments and dependence on staff for eating. Observations showed that these residents, who had diagnoses including intellectual disabilities, epilepsy, and mixed receptive-expressive language disorder, were left waiting for their meals or for staff assistance while other residents were already being served or assisted. In several instances, these residents waited significantly longer than others, with delays ranging from 14 to 58 minutes after other residents had begun eating or receiving assistance. Staff interviews and observations revealed that staffing shortages and prioritization of residents contributed to the delays. Nursing assistants reported being short-handed and having to decide which residents to assist first, resulting in some residents waiting extended periods before being served or assisted with their meals. The Director of Nursing Services acknowledged that staffing levels were based on supervision needs rather than the actual assistance required for feeding, and expected staff to call for additional help if needed. These actions and inactions led to a lack of inclusion and decreased dignity for the affected residents.