Failure to Provide Ordered 1:1 Feeding Assistance and Nutritional Supplement
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional standards, and the resident’s care plan for a resident requiring one-to-one assistance with meals and supplements. The resident, who was readmitted with dementia, hemiplegia/hemiparesis following a stroke, and a history of repeat falls, had a BIMS score of 3/15 indicating severe cognitive impairment and required supervision or touching assistance with meals. A nutritional assessment documented gradual weight loss over six months with varied intake and recommended continuation of Glucerna 237 cc PO three times daily. The care plan, last revised in mid-January, specified one-to-one feeding assistance with all meals. Physician orders included Glucerna 237 cc PO three times daily, one-to-one assist with meals, and one-to-one feeding. Despite these orders and care plan interventions, surveyor observations showed the resident seated in a wheelchair with a lunch tray placed in front and attempting to self-feed while the right arm was strapped to the wheelchair support, limiting effective use. During this continuous observation, the resident’s tablemate repeatedly stated that the resident could not feed themself and expressed a desire to help, while a nursing assistant stated that the resident was going to feed themself and acknowledged later that one-to-one assistance was not being provided until the surveyor pointed it out. The charge RN assigned to the resident reported being unaware of the one-to-one meal assistance requirement, though he acknowledged the existence of the physician order. In a subsequent observation, the resident was left with a cup containing a brown liquid identified as the ordered Glucerna supplement and was unable to lift the cup to drink; the medication technician confirmed it was the supplement and only assisted the resident after the surveyor brought it to her attention. The DNS stated that her expectation was that staff would provide one-to-one assistance with meals and ensure the supplement was administered without needing surveyor prompting.
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