Failure to Provide Physician-Ordered Adaptive Feeding Equipment
Penalty
Summary
The facility failed to provide physician-ordered adaptive feeding equipment for one resident, despite clear documentation in the resident's care plan and physician orders. The resident, who had diagnoses including encephalopathy, dysphagia, and dementia, was admitted with a need for adaptive utensils to aid in self-feeding. Observations showed that the resident's meal tray did not include the required adaptive equipment, and the meal ticket did not indicate the need for such equipment. Interviews with staff confirmed that the dietary department was not aware of the order for adaptive utensils, and the process for communicating such orders was not followed. Review of the resident's records revealed that the care plan and physician orders specified the use of adaptive utensils during all meals, and the nutritional assessment noted the resident's use of adaptive feeding equipment. However, the dietary manager confirmed that the meal ticket lacked this information, and the dietary staff did not have access to physician orders. The rehabilitation director stated that changes to diets or adaptive equipment were typically hand-delivered to dietary, but in this case, the order was missed and not communicated, resulting in the resident not receiving the necessary adaptive equipment.