Failure to Ensure Proper Use of Adaptive Eating Equipment
Penalty
Summary
A deficiency occurred when a resident with muscle weakness, osteoarthritis, and Alzheimer's disease, who required adaptive equipment for eating, was not properly supervised during mealtime. The resident's care plan specified the use of a plate guard and a two-handled cup to prevent spillage, and the Minimum Data Set indicated the resident had impaired cognition and required setup or clean-up assistance with eating. During observation, the resident was seen eating independently with a plate guard, but the opening of the plate guard was incorrectly positioned, resulting in a moderate amount of food spilled on the tray and the resident's clothes. Staff interviews confirmed that the plate guard should have been positioned to allow the resident's dominant hand to use it effectively and minimize spillage. The facility's policy required that residents have adaptive equipment as indicated to maintain or improve their functional level, and that staff observe the effectiveness of such equipment. However, the improper positioning of the plate guard and lack of appropriate supervision during the meal led to ineffective use of the adaptive device, as evidenced by the food spillage and the resident's inability to maintain independence during mealtime.