Failure to Provide Timely Feeding Assistance to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with eating for two residents who required feeding assistance. During a lunch observation on the second-floor north hall, no meal trays had been delivered by 12:30 PM, and one resident who required assistance with eating was observed watching another resident eat food that did not appear to be provided by the facility. Trays began to be passed at approximately 12:50 PM, and by around 1:02 PM the nearby resident received a tray, but the dependent resident still had not received lunch. A tray for another dependent resident was delivered to their room at approximately 1:03 PM and left on the entryway counter, with staff not entering to assist until about 1:14 PM. By approximately 1:23 PM, the first dependent resident still had not received a lunch tray and was observed taking and eating a half-eaten cup of chocolate ice cream from the other resident’s tray. When questioned, the nurse on duty stated that the resident needed assistance with eating and that there were not enough staff to help all residents needing feeding assistance at the same time, estimating at least four or five such residents on that hall. Further record review and interviews showed that one of the residents had Parkinson’s disease, depression, muscle weakness, and contracted hands, with an MDS indicating cognitively intact status and dependence on others to bring utensils and liquids to the mouth once the meal was placed in front of them. This resident reported needing assistance with most activities, including eating, and stated they always needed help with meals because they could not use their hands, sometimes did not receive the ordered mechanically soft diet, and at times waited hours to be changed. The other resident had Alzheimer’s disease, dementia with psychotic disturbance, and metabolic encephalopathy, with an MDS BIMS score indicating severe cognitive impairment and an order allowing one mechanical soft snack daily for pleasure with supervision. During an interview, the Administrator stated the facility was well staffed but acknowledged there were times when they were not clear about the timing of services provided.
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