Failure to Provide Post-Meal Clean-Up Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide post-meal care necessary to maintain a resident’s dignity. Resident #32, admitted on 03/22/23, had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, morbid obesity due to excess calories, aphasia following cerebrovascular disease, cerebral infarction due to occlusion or stenosis of the right middle cerebral artery, major depressive disorder, anxiety, bipolar disorder, vascular dementia, hyperlipidemia, chronic kidney disease, and lack of coordination. The resident’s care plan, last revised on 11/03/25, identified a risk for ADL performance deficits related to generalized weakness, decreased strength and endurance, decreased activity tolerance, impaired mobility, and incontinence related to a cerebrovascular accident. The care plan specified that the resident required increased assistance with ADL performance and was able to eat with set up and clean up assistance. On 01/05/26 at 3:46 P.M., surveyor observation revealed Resident #32 resting in bed watching television with corn on his shirt from lunch, indicating that post-meal clean up assistance had not been provided. During an interview at the time of observation, the resident stated he was not aware of the corn on his shirt and expressed upset that he had not been cleaned up after lunch. At 3:48 P.M., an interview with LPN #604 confirmed that the resident had corn on him and that he was upset about not being cleaned up from lunch. Review of the facility’s “Dignity” policy, last revised 8/25, showed that staff were expected to groom residents as they wish to be groomed and to promote resident independence, which was not followed in this instance.
