Failure to Provide Ordered Assistive Eating Devices
Penalty
Summary
A deficiency occurred when staff failed to provide a resident with the assistive eating devices as ordered by the physician. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis following a cerebral infarction, required set-up assistance with eating and was specifically ordered to use a divided plate with dycem underneath and left angled black ridged non-weighted utensils for all meals. Occupational therapy and physician documentation confirmed the ongoing need for these adaptive devices, and a dietary slip was completed to communicate these requirements. During a lunch meal observation, the resident was found without the required divided plate and utensils. Both the resident and his sister confirmed that these items were necessary for him to eat independently, as he used the edge of the divided plate to assist with getting food onto his utensils. The Dietary Manager initially indicated that the adaptive equipment had been discontinued and the resident was not listed as needing them, but later confirmed that current dietary communication sheets still indicated the need for these devices. The resident did not receive the ordered adaptive equipment during the observed meal.