Failure to Maintain Dignity and Supervision During Dining
Penalty
Summary
Failure to ensure dignity with dining occurred when a male resident with Alzheimer’s disease, type 2 diabetes, and anxiety, who was assessed as dependent for eating and required CNA assistance with meals, was left without appropriate meal service and supervision in the dining room. His care plan and orders specified a regular, mechanical soft (Level 3 Advanced) diet with thin liquids and enriched foods three times daily, and the Kardex indicated CNAs were to assist him with meals as needed. On one occasion, he was the last resident served and did not receive his meal tray until 14 minutes after he was observed sitting alone at a table. On a subsequent occasion, he was seated with two other male residents who had plates of food, while he had no food in front of him. During this later meal observation, an unknown resident pushed an open milk carton across the table to him, which he then drank. He subsequently reached into the place setting of the resident next to him, took that resident’s dessert bowl and spoon, and began eating it, then took the same resident’s plate and continued eating the remaining food. The resident whose food was taken verbally protested with single words such as “Hey!” and “Mine!”, while the first resident moved his arm to keep the plate out of reach. Throughout these events, multiple CNAs were present in the dining room and the social worker was seated at the nearby nurse’s station, but no staff observed or intervened until after the resident had consumed other residents’ food. The DON later stated his expectation was that each resident at a table be served at the same time and that meal trays be served timely.
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