F0550

E

Failure to Maintain Dignity and Proper Positioning During Assisted Feeding

Brookshire, Texas Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves staff failing to treat residents with respect and dignity and to provide meal assistance in a manner that promotes quality of life, as required by facility policy and resident rights. Surveyors observed that a licensed vocational nurse (LVN B) stood while feeding lunch to Resident #1 in the dining room, rather than sitting at eye level. Resident #1, an elderly female with dementia, dysphagia following cerebrovascular disease, epilepsy, Parkinson’s disease, and depression, had a severely impaired BIMS score of 5 and was dependent on staff for eating. Her care plan identified risk for malnutrition related to a mechanically altered diet and need for assistance with eating, with interventions to monitor for signs and symptoms of dysphagia. Despite this, LVN B stood at the resident’s left side while feeding a mechanical soft diet.

Surveyors also observed that CNA A stood while assisting Resident #2 with his lunch. Resident #2, an elderly male with cerebral infarction, GERD without esophagitis, epigastric pain, lack of coordination, and dysphagia, had a BIMS score of 8 indicating moderately impaired cognition. His MDS showed he required setup or clean-up assistance with eating, and his care plan noted an ADL self-care performance deficit related to fatigue and impaired balance, with an intervention stating he was independent with eating. His physician orders included a regular diet with pureed texture and thin liquids. During the meal observation, CNA A initially set up the food and then began feeding Resident #2 while standing at his right side, left the resident briefly during which the resident fed himself ice cream, and then resumed feeding while still standing until instructed by another CNA (CNA C) to sit.

Interviews confirmed that the observed feeding practices were inconsistent with facility expectations and policies. CNA C stated she was taught in CNA school to never stand while feeding a resident but to sit at eye level to avoid making the resident feel threatened and to respect the resident. LVN B acknowledged that staff should not stand while feeding residents and admitted he knew he should sit, later recognizing that being fed by someone standing would feel disrespectful. CNA A reported he had been instructed to sit and make eye contact when feeding residents but chose to stand because he saw LVN B standing and did not want LVN B to “look bad.” The ADON and DON both stated staff were supposed to sit at eye level when assisting with feeding to assess swallowing and preserve dignity and respect. Resident #2 reported he did not like when staff stood while feeding him, stating it made him feel bad. Facility policies on Assistance with Meals and Resident Rights specified that residents should be assisted with meals in a manner that meets individual needs, with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals, and that employees must treat all residents with kindness, respect, and dignity.