Failure to Ensure Dignified Meal Service and Proper Feeding Assistance
Penalty
Summary
The facility failed to uphold residents' rights to dignity and self-determination during meal service for two residents. One resident with moderate cognitive impairment and a history of dysphagia, diabetes, and malnutrition was not served her meal at the same time as others at her dining table. Despite raising her hand and expressing hunger multiple times, her meal was delayed by nearly 20 minutes due to disorganization in the kitchen following a staff call-out and late arrival. The resident's meal was mistakenly sent to her floor instead of the dining room, and she only received her food after staff were alerted to the error. Another resident, who had severe cognitive impairment and required assistance with eating due to Alzheimer's dementia and dysphagia, was observed being fed by a nursing assistant who stood at the side of the bed rather than sitting at eye level, as required. Although a chair was available in the room, the nursing assistant did not use it. Both the nursing assistant and the facility administrator confirmed that staff are expected to sit when feeding residents, but this protocol was not followed during the observed meal.