Failure to Provide Prescribed Assistive Drinking Device
Penalty
Summary
A deficiency was identified when a resident with a medical diagnosis of encephalopathy and an order for a regular diet with a Kennedy Cup, built-up fork, and spoon was not provided with the prescribed assistive drinking device. The resident's physician order, dated May 21, 2025, specified the use of a Kennedy Cup, which is a spill-proof cup with a secure lid and J-shaped handle, to assist with drinking. Observations conducted over three consecutive lunch services revealed that the resident was instead drinking from a regular cup with a straw, contrary to the physician's order. Interviews with facility staff, including the unit manager RN, confirmed awareness that the resident was not using the Kennedy Cup as ordered. The Nursing Home Administrator and Director of Nursing were not aware of the resident's lack of access to the prescribed assistive device until the issue was presented to them. The resident's care plan indicated a need for assistance with meals due to intellectual disability and a stable weight, further supporting the necessity for the assistive device. The failure to provide the required Kennedy Cup constituted noncompliance with regulations regarding assistive devices for eating and drinking.
Plan Of Correction
The facility cannot retroactively correct this issue. Resident 7 was given a Kennedy cup for all meals. DON/Designee conducted a facility-wide audit of residents who have orders for adaptive equipment to ensure appropriate adaptive equipment was in place during meals. DON/Designee educated Nursing/Dietary staff on the importance of assuring that assistive devices ordered are in place during meals. DON/Designee will conduct meal observations weekly x 4 then monthly x 3 or until compliance is achieved to verify adaptive equipment ordered is present during meals. Results will be discussed at the monthly QAPI.