Failure to Provide Physician-Ordered Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment, specifically Kennedy cups, as ordered by physicians and indicated in care plans for three residents with significant medical needs. Clinical record reviews showed that these residents had diagnoses such as dysphagia, protein-calorie malnutrition, muscle wasting, lack of coordination, and legal blindness, all of which required the use of adaptive equipment to ensure safe and adequate nutrition. Despite physician orders and care plan interventions specifying the use of Kennedy cups, observations during meal service revealed that dietary staff did not provide the required equipment on the residents' meal trays. Further, meal tickets for these residents clearly indicated the need for Kennedy cups, yet the equipment was not supplied at the time of meal delivery. Staff interviews confirmed that this was a recurring issue, with nurse aides reporting frequent omissions by dietary staff, resulting in interruptions to meal service as nursing staff had to contact the kitchen to obtain the necessary equipment. The Dietary Manager acknowledged the facility's failure to consistently provide the adaptive dining equipment as ordered.