Failure to Provide Adaptive Drinking Equipment for Resident with Tremor and Swallowing Issues
Penalty
Summary
A deficiency occurred when a resident with diagnoses including type 2 diabetes mellitus, essential tremor, mild cognitive impairment, and a history of swallowing problems was not consistently provided with the adaptive drinking equipment specified in their care plan. The care plan required the use of a two-handled mug with a spouted lid for all beverages, as well as other adaptive utensils, to address the resident's tremor and risk of aspiration. Observations over multiple meals showed that the resident was frequently given drinks in standard cups, mugs, or glasses without lids or straws, resulting in repeated spills and an inability to consume fluids independently. Staff were present in the dining area but did not ensure that all beverages were transferred into the appropriate adaptive cups as required by the care plan. Interviews with staff confirmed that the resident was supposed to have multiple adaptive cups for different beverages, but this was not consistently provided. The LPN acknowledged the resident's need for covered drinks and noted that only one adaptive cup was typically provided. The dietary supervisor stated that the kitchen had sufficient adaptive cups available and that it was the responsibility of the floor staff to transfer beverages and request additional cups as needed. The speech language pathologist and RN unit manager both confirmed the expectation for multiple adaptive cups to be available for residents requiring them. Despite these care plan interventions and staff awareness, the resident was observed struggling to drink and eat independently, with significant portions of meals and fluids left unconsumed due to the lack of appropriate adaptive equipment.