F0550

D

Failure to Maintain Dignity During Assisted Feeding

Dallas, Texas Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to treat residents with respect and dignity and to provide care in an environment that promotes quality of life during mealtimes. Surveyors observed that during a lunch meal, a Speech Therapist stood while feeding one resident and an LVN stood while feeding another resident for the entirety of their meals. The facility’s DON stated that staff were expected to sit at the same level as residents when feeding them, and also acknowledged that the facility did not have a feeding policy. The Speech Therapist admitted she had known for over a year that standing while feeding a resident was a dignity issue, but chose to stand because the dining room was full and she wanted to provide the meal quickly, and she did not request a chair.

The first resident was an older female with major depressive disorder, type 2 diabetes, dementia, dysphagia, and anxiety disorder. Her MDS showed severe cognitive impairment with a BIMS score of 00, and her care plan for potential nutritional problems and functional decline due to dysphagia included providing a calm, quiet setting at mealtimes with adequate eating time. The second resident was an older female with vascular dementia, dysphagia, and schizoaffective disorder, whose MDS indicated she was severely impaired and dependent on staff for eating, with a care plan focus on ADL self-care performance deficit and an intervention requiring substantial/maximal staff assistance with eating. The LVN who fed the second resident while standing stated she was not aware she should not stand while feeding and acknowledged that the resident could have felt intimidated. The DON and staff interviews confirmed that residents were at risk of choking and not having a dignified experience during their meals when staff stood over them while feeding.