Failure to Provide Adaptive Eating Equipment as Recommended by Therapy
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and recent right-hand weakness did not consistently receive adaptive eating equipment as recommended by occupational therapy. The resident had a history of dementia and physical limitations, including a right-hand wrist drop, which led occupational therapy to recommend and implement the use of built-up handled utensils and two-handled cups to support the resident's independence during meals. Despite these recommendations, observations by the surveyor revealed that the resident did not have access to the required adaptive utensils and cups during two out of three observed meals. At times, the resident was left without staff assistance, resulting in spilled food and difficulty eating. Interviews with facility staff indicated confusion and lack of clarity regarding responsibility for ensuring the adaptive equipment was provided and documented in the care plan. The occupational therapist reported informing both unit and kitchen staff of the resident's needs and providing education sheets to the restorative nurse, who was expected to update the care plan. However, the restorative nurse did not place the necessary orders, and the dietary supervisor had not received the order through the nutrition management system, so the care plan was not updated to reflect the adaptive equipment requirement. Staff interviews also revealed uncertainty about where information regarding adaptive equipment could be found, and some staff were unaware of the resident's current needs. Documentation showed that certified nursing assistants were recording the use of adaptive utensils in their daily charting, but this was not consistently reflected in the resident's care plan or meal setup. The lack of coordination among therapy, nursing, restorative, and dietary departments led to the resident not receiving the prescribed adaptive equipment during meals, as observed by the surveyor. This failure to provide necessary adaptive eating devices as recommended by therapy and outlined in facility policy resulted in the identified deficiency.