Failure to Provide Required Feeding Adaptive Equipment at Meals
Penalty
Summary
Staff failed to provide a resident with the required feeding adaptive equipment at each meal, despite a physician's order and clear documentation on the resident's meal card indicating the need for built-up utensils. The resident, who had a history of stroke and significant difficulty eating without adaptive equipment, reported that the specialized utensils were usually missing from her meal tray. On multiple observed occasions, the resident's tray was delivered without the necessary adaptive device, and she had to request assistance from a CNA to obtain it, resulting in her food becoming cold before she could eat. Review of facility policy confirmed that residents should be assessed for adaptive equipment and provided with it as needed to facilitate independence. Interviews with the Dietary Manager and Administrator confirmed that there were sufficient devices available and that staff were expected to provide them when ordered by a physician. However, observations and interviews demonstrated that the process was not consistently followed, leading to the resident not receiving the required adaptive equipment at mealtimes.