Surveys: Dietary/Special Eating Equipment
Posted by Patti on January 25th, 2005 / Print This Post
Survey Date: 5/5/2004
Regulation Number:0369, level D scope/severity
Regulation Title: DIETARY SERVICES
Regulation Description: The facility must provide special eating equipment and utensils for residents who need them.
Surveyor Findings:
Based on observation, record review, staff and resident interviews, the facility failed to provide special eating equipment for one (#4) of 24 sample residents. Specifically, the facility failed to provide resident #4 with ordered and care planned built-up utensils and lip plate or plate guard. This failure created the potential for frustration and this resident’s activities of daily living (ADLs) to decline, rendering the resident dependent for feeding, rather than independent. The findings were:
Interviewable resident #4 was admitted to the facility 04/30/01 with diagnoses that included Parkinson’s, depressive disorder, essential hypertension, vitamin B-complex deficiency, and constipation. The resident’s Minimum Data Set (MDS) ratings dated 04/18/04 and 01/29/04 for eating were 2 and 2, indicating limited assistance necessary and one-person physical assist necessary.
Observation in the assisted dining room on 05/04/04 at 8:30 a.m. showed a CNA placing a plate of breakfast food on the table in front of the resident. Observation showed the plate was not lipped, but a standard plate without a plate guard.
At 8:42 a.m. and 8:43 a.m., the resident was observed taking small bites of pureed eggs and pureed biscuits and gravy with a regular spoon. There was no built-up silverware on the table for the resident to use. The resident was scooping the food, using the regular spoon in his right hand, knuckles up.
At 12:18 p.m., the resident was observed using a regular fork with his right hand. The resident was scooping food off a regular plate that did not have a plate guard or a lipped edge.
Observation in the assisted dining room on 05/05/04 at 8:15 a.m. showed the resident was served a plate of breakfast foods. The plate did not have a plate guard or lipped edge. At 8:16 a.m., the director of nursing (DON) entered the assisted dining room and stated, “You have no silverware (built-up).” At 8:19 a.m., the DON stated, “and you have the wrong plate.” The DON explained how a lipped plate would make it easier to scoop his food, and the resident agreed. The DON was observed rising to exchange the regular plate for a lipped one and stated, “let me get you different silverware, too.”
Observations at 8:23 a.m. showed the resident attempting to use the weighted, built-up spoon. The DON stated the weighted spoon was too heavy, and left the assisted dining room to find an occupational therapy representative (OTR).
At 8:30 a.m., the DON returned with the OTR, who suggested a foam utensil rather than a weighted one. At 8:32 a.m., observation showed the OTR had returned to the assisted dining room with a washcloth and spoon. The OTR was observed wrapping the washcloth around the regular spoon and taping it tight.
At 8:39 a.m., the resident was observed trying to use the washcloth-covered, built-up spoon. He was largely unsuccessful; the spoon was put in his hand as one would hold a pen. Observations had shown the resident preferred to hold utensils in a closed fist with his knuckles facing upward. This position allowed the resident to maximize the utensil surface by keeping it flat as he scooped the food.
At 8:41 a.m., observation showed the OTR placing her hand on the outside of the resident’s hand on the washcloth-covered, built-up spoon to guide the resident in loading food and moving it to his mouth.
At 8:48 a.m., observations showed the OTR feeding the resident with no assistance from the resident. The OTR and DON discussed trying a rocker spoon at lunch. The OTR stated, “He’s done trying for now.”
Record review of a plan of treatment for outpatient rehabilitation dated 02/05/04 stated “use built-up utensils and plate guard.” Nutritional assessments dated 04/07/03, 06/30/03, 10/03/03, 12/13/03, 02/01/04, and 04/30/04 listed lip plate under the adaptive devices category.
Record review of the dietary card indicated “lip plate/weighted utensils.” The dietary card was updated after an interview on 05/04/04 with the DON and nursing home administrator (NHA).
Record review of an interdisciplinary progress note dated 02/04/04 at 12:00 p.m. indicated, “Patient screened by skilled OT (occupational therapist) for feeding. Patient having increased difficulty feeding self per CNAs.” An interdisciplinary note dated 02/05/04 stated, “OT eval completed. Recommend 5-6 visits x 2 weeks to address feeding.” An interdisciplinary note dated 02/16/04 at 5:30 p.m. stated, “Self feeding setup SBA with weighted spoon/plate guard . . . patient liked weighted spoon.”
Record review of a dietary progress note dated 12/13/03 stated, “Continues to feed self independently and lip plate provided.”
Record review of a care plan with a target date of 05/03/04 indicated lip plate as an approach to maintaining weight. A care plan dated 02/20/04 indicated a problem of decreased ability to feed self with standard plate and utensils. The OT goal listed was that the patient would feed self using built-up utensils and a plate guard. The approach listed was “patient to be provided with built-up utensils and plate guard at every meal, to eat in assisted dining room.”
During an interview on 05/04/04 at 3:30 p.m. with the DON and NHA, it was indicated the dietary department was responsible for setting out adaptive devices, such as built-up utensils, as ordered. The dietary department was also responsible for providing plate guards or lipped plates, as appropriate.
During an interview with the resident on 05/05/04 at 3:37 p.m., the resident stated, “that plate guard is okay. That special plate (lipped plate) is pretty neat - your food doesn’t fall off your plate.”
Facility Plan of Correction:
1. Resident #4 was provided built-up silverware and a lipped plate on 5/4/04 and the dietary card was updated to include “lip plate/weighted utensils”. 2. A facility audit will be completed to identify residents who have recommendations for adaptive equipment. Dietary cards will be audited to ensure adaptive equipment is listed on the residents’ dietary cards. 3. An in-service for nursing staff was conducted on 5/19/04 and 5/20/04 on adaptive equipment and providing special eating equipment and utensils for residents who have been assessed to need them. Dietary staff will be in- serviced the week of 6/1/04 on how to identify different types of adaptive equipment and the responsibility of setting out this equipment for identified residents. 4. Dietary Manager, Dietitian and/or designee will monitor weekly and as needed for compliance. The results of the above audits/reviews, and related action plans will be reported to and reviewed by the Performance Improvement Committee x90 days and quarterly thereafter.