Failure to Ensure Timely Meal Service and Privacy, Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity and that their quality of life was maintained or enhanced. One resident with diabetes, cerebral palsy, anxiety disorder, and intact cognition, who required set-up assistance with meals, experienced repeated and significant delays in meal service compared to other residents. During a dining observation, this resident remained the only person in the dining room without a meal for more than 45 minutes after trays began being passed, watching others eat while being told by an LPN that the meal would arrive shortly. The resident eventually left the dining room without having been served and later received the meal in their room, after the LPN acknowledged the meal ticket had been completed that morning and that the meal should have arrived with the others. Interviews and record review showed that this resident routinely received meals later than others, with delays sometimes lasting 30 minutes to an hour, and that the resident reported feeling bad and frustrated while waiting and watching others eat. A CNA stated they frequently contacted the kitchen about this resident’s meal and were often told it would take additional time, even when other residents had already been served. The RN Manager confirmed it was problematic that the resident did not receive their meal for more than 45 minutes after others and that the meal ticket had been reviewed by the dining services supervisor, who could not explain why the meal was not placed on the cart. The dining services supervisor acknowledged that residents seated together were not always served together and attributed this to lack of attentiveness to seating sheets, while the DON confirmed awareness of dining concerns and that other residents had reported long wait times. A second deficiency involved another resident with paraplegia, traumatic brain injury, severe cognitive impairment, and a feeding tube, whose care plan and CNA Kardex documented a preference not to wear clothing in bed and a requirement that the privacy curtain remain drawn at least halfway. Observations showed this resident lying in bed unclothed with the room door open and genitals exposed, visible from the hallway, and on another occasion lying in bed wearing only an incontinence brief with stool present between the legs, again visible from the hallway. Staff interviews revealed that the room lacked a privacy curtain, and staff sometimes left the bathroom door open or covered the resident with a top sheet in an attempt to conceal the resident while honoring the preference to be unclothed. The RN Manager stated staff attempted to preserve the resident’s dignity by covering them but was unaware the resident was frequently visible from the hallway, and the DON acknowledged it was not dignified for the resident to be visible from the hallway while unclothed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.