Failure to Maintain Resident Dignity and Proper Supervision During Meal Service
Penalty
Summary
Facility staff failed to maintain resident dignity during meal distribution on one of two units, as evidenced by several observed actions and inactions. Staff did not serve all residents at the table simultaneously, and some residents in the TV room experienced significant delays in receiving their meals. Staff entered multiple resident rooms without knocking or announcing themselves, and did not consistently perform hand hygiene between assisting different residents. During meal service, a resident dependent on staff for feeding was left with a meal tray in front of him without immediate assistance, and another resident poured his beverage over his food without staff noticing or offering a replacement meal. Additionally, staff were observed standing while feeding residents, despite available chairs, rather than sitting beside them as required by facility policy. Interviews with the DON confirmed that staff were expected to knock before entering rooms, perform hand hygiene between residents, and sit beside residents while assisting with feeding. The DON acknowledged that residents needing assistance were to be served last to allow staff to help them, but observations showed lapses in supervision, such as a resident taking another's fork and lack of immediate staff presence. The facility's policy on promoting and maintaining resident dignity during mealtimes was reviewed, which included requirements for respectful treatment and sitting while feeding residents. However, the facility did not have a specific policy regarding meal distribution, and the observed practices did not align with the stated expectations.