Failure to Maintain Resident Dignity and Provide Required Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide meal assistance and maintain dignity for two residents with significant cognitive and physical impairments. One resident had a history of stroke with upper and lower extremity weakness on the dominant side, aphasia, and dysphagia. An MDS assessment indicated cognitive impairment, functional impairment of the dominant side limbs, and a need for supervision or assistance with eating, including intermittent cueing or steadying. The resident’s care plan specified setup and supervision at all meals, use of a plate guard, and placement of all supplies within reach. During a lunch observation, the resident was seen seated in the dining room licking gelatin from the manufacturer’s cup without utensils within reach. Staff briefly pushed the tray to the center of the table, served cereal in a bowl with a spoon, and then left the resident with the spoon and gelatin cup. The resident struggled to eat, spilling some on the floor, until staff returned and removed the tray, spoon, and unfinished gelatin. The second resident had diagnoses including Parkinson’s disease, dementia, and a history of stroke with upper and lower extremity weakness on the non-dominant side. An MDS assessment showed cognitive impairment and a need for substantial assistance from staff, and a speech therapy dysphagia assessment indicated the resident should have assistance for all meals. During a lunch observation, this resident was seated alone in a wheelchair facing the television and wall at the far end of the room from the nurses’ station, with a meal tray in front of her. Spilled milk was observed on the tray, and the resident was eating packaged gelatin by sucking it through a straw. She declined to eat the remainder of her meal, and staff did not provide assistance until they removed her tray. In an interview, the Administrator confirmed that staff should have provided assistance to both residents during meal service.
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