Failure to Provide Ordered Adaptive Drinking Equipment and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed adaptive drinking equipment and to ensure staff verified diet slips against meal trays. A resident with hemiplegia and hemiparesis following a nontraumatic intracranial hemorrhage had a physician’s order, dated 7/31/25, for a spouted cup with handle with all meals. The resident’s care plan, last reviewed 9/25/25, identified nutrition/hydration risk and included an approach to provide adaptive equipment with meal trays as ordered, specifically a spouted cup with handle. The quarterly MDS documented moderate cognitive impairment, impairment of one upper and one lower extremity, and independence with eating after tray setup. On observation, the breakfast tray diet slip specified a spouted cup with handle, but the tray contained only regular cups with lids and straws, and the beverages appeared untouched. Later observation of the lunch meal showed a nurse aide delivering the tray, placing it on the overbed table, removing the plate lid, and attempting to leave without checking the diet slip. When questioned, the aide initially stated she had not checked the diet slip and that they “didn’t really say anything,” then, after looking, failed to notice the spouted cup order and incorrectly stated the resident was not supposed to have one before correcting herself. She acknowledged that when a tray does not match the diet slip, she “just leaves it and hopes for the best,” despite having been trained on tray passing at hire. The resident reported sometimes spilling drinks when using a regular cup with lid and straw and that the spouted cup with handle was easier to use. The DON stated that staff passing trays were responsible for checking diet slips and returning incorrect trays to Dietary, and the Dietary Manager reported that multiple staff checked trays before carting and that there was adequate stock of spouted cups, yet the resident still received breakfast and lunch without the ordered assistive device.
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