A facility failed to provide ordered adaptive eating equipment and utensils at mealtimes for multiple residents. Residents were observed without Dycem, a scoop plate, or the ordered Kennedy cup despite tray cards and physician orders indicating these items, and staff confirmed the equipment was not present or had never been provided. One resident was also seen drinking from a regular coffee cup instead of the ordered special cup.
Adaptive Cup Positioned Incorrectly During Meals: A resident with an order for a two-handled cup and concave lid was observed unable to get thickened liquids from the cup because the opening was positioned incorrectly. Staff confirmed the resident could not drink until the cup was turned around or assisted, and the SLP stated the cup was intended to reduce bolus size because the resident takes large drinks.
The facility failed to ensure ordered eating assistive devices were available and properly used for two residents. One resident with cognitive deficits, malnutrition risk, low BMI, and partial assistance needs for eating and drinking did not have a Kennedy cup at bedside despite an order and care plan intervention. Another resident with an order for a suction divided plate was served with the plate set inside the cover so it was not suctioned to the table, and the CNA later acknowledged it should have been suctioned when served.
Failure to provide ordered plate guard. A resident with hemiplegia and legal blindness had an order for a regular diet with plate guard and built-up utensils, but the plate guard was missing from the meal tray during observation. The diet ticket listed the plate guard, and the Administrator confirmed it was supposed to be provided.
Failure to provide ordered adaptive drinking equipment. A resident had a physician order for a Kennedy cup with meals and at bedside, but staff observed a lidless coffee cup on the overbed table and the lunch tray arrived without the ordered cup. The RN confirmed the tray ticket called for the Kennedy cup and then retrieved one from the beverage cart.
Failure to Provide Ordered Slow-Sip Cup: A resident with a history of swallowing and choking problems, edentulous status, and a mechanically altered diet was observed in the dining room with milk cartons and straws but no slow-sip cup, even though the cup was listed on the meal ticket. An RN confirmed the resident should have had the cup, and the SLP also stated the resident should have it.
Failure to provide ordered adaptive drinking equipment occurred when a resident was observed at a meal without the nosey cup listed on the tray card. An NA served cold tea, orange juice, and milk in regular clear plastic cups and stated they were not familiar with a nosey cup, despite the care plan calling for thickened liquids, no straws, and a nosey cup for all fluids due to Huntington's disease, dementia, and a hx of TBI.
A resident did not receive a physician-ordered Kennedy cup during a meal in the dining room. The resident’s diet order, care plan, and tray card all specified the adaptive cup, but an RN confirmed it was not being used and noted the resident was doing well without it.
A resident did not receive their meal in bowls as specified by their dietary order and tray card, with only dessert served in a bowl. This was confirmed by a nursing assistant, despite facility policy requiring assistive devices and utensils to be provided according to the care plan.
A resident with dysphasia and an order for thin liquids, advanced texture, and a Kennedy cup with all meals was observed at lunch without the ordered cup. An RN served the meal tray, opened the resident’s milk, and placed a straw in it, then confirmed the Kennedy cup was not provided as ordered and written on the meal ticket.
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