Failure to Provide Adaptive Eating Equipment During Meals
Penalty
Summary
A deficiency occurred when a resident with dysphagia, generalized muscle weakness, and severe cognitive impairment was not provided with adaptive eating equipment as ordered and recommended. During a meal observation, the resident did not have a plate guard or a two-handled cup with a lid, resulting in food spilling off the plate and onto the table and clothing. The CNA present stated that she frequently reminded kitchen staff to provide these items, and the SLP confirmed that the resident should have had these assistive devices during meals, as previously recommended to support self-feeding and prevent spills. Record reviews showed that the resident's meal ticket, SLP evaluation, and physician orders all specified the need for a plate guard and two-handled cup with lid at all meals. Facility policy also required that adaptive devices be provided as ordered and documented on tray cards. Despite these documented needs and orders, the resident did not receive the necessary adaptive equipment during the observed meal.