Failure to Provide Required Feeding Assistance and Oral Hygiene
Penalty
Summary
The facility failed to ensure that residents requiring assistance with Activities of Daily Living (ADLs), specifically grooming, eating, and oral hygiene, received the necessary services as outlined in their care plans and facility policies. Observations and interviews revealed that two residents who needed feeding assistance during meals did not consistently receive the required help. One resident with chronic fatigue, high blood pressure, and oropharyngeal dysphagia experienced significant weight loss and was observed struggling to feed themselves due to hand tremors and decreased alertness. Despite being listed as needing feeding assistance, staff were unclear about the resident's needs, and there was no documentation indicating the requirement for feeding assistance. Staff often relied on verbal reports rather than written care plans, leading to inconsistent care during mealtimes. Another resident with Alzheimer's disease, tremors, and cognitive deficits was documented in physician orders as needing to be fed at all meals. However, this resident was not included on the facility's list of residents requiring feeding assistance, and staff did not consistently provide the necessary help. Observations showed the resident playing with food and not eating until prompted and fed by staff, indicating a lack of awareness among staff regarding the resident's care needs. Interviews with staff and the DON revealed a lack of knowledge about which residents required feeding assistance, with some staff believing the resident only needed encouragement rather than direct feeding. Additionally, a resident with severe cognitive impairment and a history of pocketing food was left with a meal tray in their room without staff attempting to wake them to eat or providing oral hygiene after meals, as directed in the care plan. Observations showed that staff did not check the resident's mouth for debris or provide oral care after meals, and documentation of meal intake and episodes of falling asleep during meals was incomplete. Staff interviews confirmed that oral care was typically only provided in the morning and evening, not after meals, even when care plans specified otherwise. These failures demonstrate a lack of adherence to individualized care plans and facility policies regarding ADL support, particularly in feeding and oral hygiene.