Failure to Promote Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide care that promoted dignity and respect for multiple residents who were dependent on assistance with eating. Certified Nursing Assistants (CNAs) were observed feeding two residents at the same time by alternating spoonfuls and beverages between them, rather than focusing on one resident at a time. This practice was observed with several residents who had severe cognitive impairment and were fully dependent on staff for eating, as documented in their Minimum Data Set (MDS) assessments. Specifically, CNA 1 was seen feeding two residents simultaneously, then later feeding another pair of residents at the same time. CNA 2 and CNA 3 were also observed feeding two residents at once. Interviews with the CNAs confirmed that this was a common practice in the facility. The facility's policy on Assistance with Meals required that residents who cannot feed themselves be fed with attention to safety, comfort, and dignity, and that staff should minimize interactions with others while assisting residents with meals. Further interviews with the Director of Staff Development (DSD) and a Licensed Vocational Nurse (LVN) revealed that CNAs were trained to feed only one fully dependent resident at a time, and that feeding two fully dependent residents simultaneously was not in accordance with facility policy. The DSD acknowledged the need to monitor seating arrangements and staff availability to ensure proper assistance during meals.