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 physician orders for a pureed diet and honey thick liquids, requiring a lidded cup and no straws due to aspiration precautions, was initially provided a beverage with a straw. The error was identified and corrected by a nurse aide after reviewing the tray ticket, and the DON confirmed the resident's need for aspiration precautions.
A resident with a physician's order for a two-handled cup was observed eating lunch with a standard cup lacking handles. The tray ticket specified the need for adaptive equipment, but the required cup was not provided, as confirmed by an RN.
Two residents were not provided with the adaptive eating devices specified in their care plans and physician orders during a meal. One resident did not receive a sip-a-mug as ordered, despite her medical history of nutritional risk and recent weight loss, while another was given a sip-a-mug instead of the [NAME] Cup indicated in his care plan. These deficiencies were confirmed by staff and the DON.
A resident with significant medical conditions and a care plan specifying the use of a three-compartment plate was served a meal on a raised lip plate instead, as kitchen staff could not locate the correct assistive device at the time. The care plan detailed the need for specific adaptive equipment to support the resident's nutritional needs.
A resident with an order for a divided plate was served a meal on a regular plate, despite documentation in the care plan and tray card specifying the need for adaptive equipment. This was confirmed by observation and review with an LPN, in violation of facility policy requiring provision of special eating utensils and equipment as ordered.
Two residents with physician orders for adaptive eating equipment, including a plateguard and grip bowl, were repeatedly served meals without the required items. One resident, at nutritional risk, did not receive a plateguard as ordered, and the equipment was not listed on the meal ticket. Another resident with dysphagia struggled to eat without a grip bowl and plateguard, and staff only provided the equipment after being notified of the omission, despite the orders being present on the meal ticket.
A resident with a contracture in his dominant hand did not receive a required plate guard during meals, as per physician's orders. This resulted in food spillage on his clothing and bedside table. The resident confirmed the plate guard was only sometimes provided, and a therapist acknowledged its absence.
The facility failed to provide appropriate assistive devices to a resident who needed them to eat independently. Despite the care plan indicating the use of a proval cup due to paralysis affecting the left extremities, the resident was not provided with the required cup because they did not like it, as stated by a nurse aide.
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