Failure to Consistently Provide Prescribed Adaptive Dining Equipment
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide prescribed adaptive dining equipment for a resident with significant cognitive and physical impairments. The resident had diagnoses including cerebral palsy and dysphagia and was documented on a quarterly MDS as being rarely or never understood, having short- and long-term memory problems, being severely cognitively impaired for decision making, and dependent on staff for eating. A physician order dated April 4, 2024, required the use of a coated spoon with all meals. However, review of the resident’s January Task Documentation Report for January 1 through January 28, 2026, showed that the coated spoon was not provided for 31 out of 84 meals served. During a lunch observation on January 29, 2026, the resident’s tray ticket indicated a coated spoon, but a plastic disposable spoon was placed on the tray instead. A nurse aide confirmed at that time that the coated spoon was not provided and further stated that the coated spoon was frequently not included on the resident’s tray. The nurse aide also reported that the resident sometimes bites down on the spoon while being fed and that the coated spoon is beneficial for the resident. The Nursing Home Administrator acknowledged that the facility failed to ensure the prescribed adaptive equipment (coated spoon) was consistently provided and used in accordance with the physician’s orders, in violation of 28 Pa. Code 211.12(d)(3)(5) related to nursing services.
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