Failure to Provide Special Eating Equipment and Dietary Orders for Visually Impaired Resident
Penalty
Summary
The facility failed to provide meals in accordance with a resident's care plan and dietary orders, specifically for a resident with visual impairment and legal blindness. The resident's care plan and diet order required all food to be served in bowls to facilitate self-feeding, as well as the provision of two cartons of milk with lunch and avoidance of whole sandwiches. Observations revealed that the resident was served food items on plates, such as a whole cheese sandwich and cake, rather than in bowls as ordered. The resident expressed difficulty eating from plates and handling whole sandwiches due to his visual impairment. Additionally, the resident consistently received only one carton of milk with meals, contrary to the dietary order for two cartons. Staff interviews indicated a lack of awareness of the resident's specific needs, with one nurse stating she was unaware of the requirement for all food to be in bowls. The dietary manager acknowledged that staff made mistakes and that the tray card was confusing, leading to errors in meal preparation and delivery. The posted instructions above the resident's bed and on the tray card were not consistently followed, resulting in the resident missing preferred foods and experiencing difficulty feeding himself.