Failure to Provide Dignified and Timely Dining Experience for Dependent Resident
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident when staff did not serve the resident's meal in a timely or appropriate manner during a lunch service. The resident had documented diagnoses including dysphagia, sialadenitis, progressive bulbar palsy, osteoarthritis, osteoporosis, and abnormal involuntary movements, with physician orders for a pureed diet and honey-thick liquids, and an MDS and care plan indicating a need for supervision or touching assistance with eating. During the observed lunch, staff (including an RN, an activity aide, and CNAs) passed trays to other residents at the same table and surrounding tables while the resident remained without a tray. Two tablemates received and began eating their meals while the resident continued to wait. The delay continued as staff seated another resident between the two tablemates and provided that resident with a tray, still without serving the resident in question. After a housekeeping staff member pointed out that the resident had not received a meal, staff moved the resident to another table where others were already eating, and only then placed a lunch tray in front of the resident. Staff did not set up the tray or thicken the resident's juice at the time the tray was delivered, despite the order for honey-thick liquids, and meal assistance did not begin until several minutes later when a CNA sat down to assist. The facility’s Food Service and Distribution policy did not include procedures or protocols on how to protect residents’ dignity while serving meals, although the facility’s Resident Rights Policy stated that residents have the right to a dignified existence and to be treated with respect and dignity.
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