Failure to Provide Required 1:1 Feeding and Lunch Meal to Dependent Feeder
Penalty
Summary
The deficiency involves the facility’s failure to provide required 1:1 feeding assistance and to ensure a lunch meal was offered and provided to a dependent resident. The resident had multiple medical diagnoses including dysphagia, cervical spine fusion with paraplegia, neurogenic bladder, type 2 diabetes, hypertension, hypotension, anemia, and muscle spasms. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and coded the resident as Dependent for eating, meaning staff must perform all of the effort for the eating task. The facility’s list of 1:1 feed residents included this resident, and the care plan documented potential nutritional problems and a need for assistance with ADLs related to paraplegia. On the day in question, the resident reported receiving morning ADL care and incontinence care from a CNA around late morning, then falling asleep and waking in the afternoon feeling hungry, with no lunch tray present and no staff having awakened the resident or offered lunch. The resident stated that no one asked whether they wanted to eat and that they were not fed lunch. A family member reported receiving a call from the resident that afternoon stating the resident was hungry and had not been given lunch, and another visitor confirmed assisting the resident to call the family because staff had not provided a lunch tray. At the time of observation during survey, the resident was in bed with bilateral hand splints, stated they could not use their arms to eat or drink independently, and stated they received full care from staff. Multiple staff interviews and record reviews showed that although the Daily Assignment Sheet for that shift listed one CNA under special assignment as the 1:1 feeder for this resident, that CNA stated they did not see or feed the resident at lunch and believed the assignment entry was a mistake. The primary CNA for the resident that day confirmed providing ADL care but stated they did not bring or feed the lunch tray and believed that whoever was assigned as feeder was responsible. Other CNAs, the RNA, and the RNs working that shift each stated they did not bring in or provide the resident’s lunch meal. The CNA who created the assignment sheet stated that all CNAs were informed of their 1:1 feed responsibilities and that the CNA listed as special assignment was responsible for feeding this resident. Despite this, no staff member identified actually delivering or feeding the lunch meal, and the ADL charting by the primary CNA documented only supervision and setup help for eating at a time corresponding to the lunch period, with no indication of 1:1 physical assistance or resident refusal. Facility policies required that residents unable to feed themselves be hand-fed by qualified staff, that diets be served per physician order, and that CNAs prepare residents for meals, feed as necessary, and review care plans daily, but these expectations were not met for this resident’s lunch meal.
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