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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: March 3, 2025
Citation Details Based on observation, interview and record review during the Standard survey conducted from 4/27/22 through 5/3/22, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Three (Units 1, 2, and 3) of three resident units reviewed for dignity with dining had an issue involving meals served on disposable plates. This involved Resident #s 9, 17, 48 and 72. The finding is: The facility policy and procedure titled Dignity dated 8/1/19 documented each resident has the right to be treated with dignity and respect. Examples of treating residents with dignity and respect include but are not limited to: promoting resident independence and dignity while dining, such as avoiding daily use of disposable cutlery and dishware. 1. During an observation on 4/27/22 at 10:38 AM, Resident #48 had a breakfast tray on tray table in front of them. The egg on the paper plate was noted absorbed into the plate. During Unit 1 meal observation on 4/27/22 at 11:48 AM, staff served resident's lunch trays with the entr??ó??«e on disposable plates covered with plastic wrap. During Unit 3 meal observation on 4/27/22 at 12:01 PM, staff served resident's lunch trays with the entr??ó??«e on disposable plates. During Unit 2 meal observation on 4/27/22 at 12:13 PM, staff served resident's lunch trays with the entr??ó??«e on disposable plates covered with plastic wrap. During an observation and interview on 4/27/22 at 12:06 PM, Resident #72 was eating their lunch and the entr??ó??«e was on a disposable plate. The Resident stated the disposable plates were terrible and once they had mashed potatoes that made a hole in the bottom of the plate. Now they knew to leave the plastic wrap under the plate to avoid a mess. During an observation and interview on 4/27/22 at 12:47 PM, Resident #48 stated the facility used paper plates and they were horrible especially in the morning when trying to eat eggs, it was hard to get the egg on the fork from the paper plate. Resident #48 stated they hated paper plates and would prefer a plate that had a hard surface. During an interview on 4/27/22 at 03:43 PM, Resident #17 stated the disposable plates were a mess and they preferred a real plate. The resident stated when they tried to remove the plastic wrap from the plate, the food got all over the place and was annoyed by it. During Unit 2 dinner observation on 4/28/22 at 6:02 PM, resident's entr??ó??«es were observed to be served on disposable paper plates. During an interview on 4/28/22 at 6:25 PM, Resident #9 stated my paper plate dissolved into my food. I couldn't eat it. Then stated they did not like the paper plates. Observation in the Main Kitchen on 4/29/22 at 11:40 AM revealed residents' food trays contained hard re-usable plastic drinking cups and soup bowls and metal utensils, but the entr??ó??«e and dessert were plated on paper plates and the food on each plate was covered with disposable clear plastic wrap. During an interview on 4/29/22 at 11:40 AM, the Food Service Director stated paper plates were used for resident meals because of kitchen staffing. They further stated residents who were care planned for re-usable adaptive plates have their food served on them, but the majority of residents received their food on paper plates. The Food Service Director stated the facility had re-usable heated plate bases with re-usable hard plastic covers that helped keep the food hot during transport, but they were not currently used in order to save the kitchen staff the time it would take to wash them. During a test tray observation on 4/29/22 at 11:56 AM, the entr??ó??«e and dessert were served on disposable plates with a tight plastic wrap covering. While removing the plastic wrap, the plate was bending, and it was difficult to remove the plastic wrap without the plate being bent. During an interview on 4/29/22 at 12:09 PM, the Food Service Director stated at the start of the COVID-19 pandemic in 2020, the facility started using all single-service food containers and utensils to serve the residents' meals for breakfast, lunch, and dinner. They further stated during Resident Council meetings, the residents voiced that they preferred metal re-usable utensils over plastic utensils, so the facility switched back to metal re-usable utensils. Additionally, the Food Service Director stated in the time since the start of the COVID-19 pandemic, the facility had switched back to re-usable cups, but had not yet transitioned back to re-usable plates. During a telephone interview on 5/3/22 at 11:50 AM, the Registered Dietician (RD) stated the residents had received paper products since they started working at the facility at the end of (MONTH) last year. The RD stated they switched to full glass with the hotplates under the plates and regular trays last summer but then staffing got bad, so they moved back to paper products. The RD stated there were a few residents that have complained, so they had offered regular glass to them. The RD stated there were no issues with getting the meals out on time from the kitchen. The RD stated the facility policy was to use reusable items and they were not aware of the facility policy regarding dignity with dining and to avoid using disposable items. During an interview on 5/3/22 at 1:54 PM, the Administrator stated they had used all disposable products during COVID-19 pandemic and now they were using only disposable plates. The Administrator stated they received complaints from resident council about the plastic utensils but not the disposable plates. The Administrator stated they never got back to using full reusable items, and they had regular plates available for resident use. During an interview on 5/3/22 at 2:39 PM, the Director of Nursing (DON) stated they did not know the facility dignity policy specifically documented to avoid the use of disposable dishware but that it made sense. The DON stated now that they knew it was upsetting some residents they needed to go back to regular plates. 415. 5(a) | Plan of Correction: ApprovedJanuary 14, 2025 The facility acknowledges resident #1 was affected by this deficient practice. Resident #1's Neurological checks sheet was reviewed, to ensure it reflected the appropriate time frame and updated accordingly. A full house audit was conducted on all resident on neurological checks to ensure they are filled out accurately by the director of nursing or designee All current resident on neurological checks were reviewed to ensure compliance with no issues identified A lesson plan was developed for education, and all LPN's and RN's will be educated on accurate documentation in the medical record and specifically the neurological checks. The facility policy on Neurological checks was reviewed on 1/6/25 with no changes made The director of nursing / designee created an audit to ensure all neurological checks are completed Accurately. The director of nursing/ designee will conduct a weekly audit on 10% of all residents on neurological checks to ensure they are completed accurately to ensure compliance x 8 weeks then monthly thereafter until 100% compliance is achieved. Any negative audit findings will be immediately address by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. The findings of these audits will be discussed by the DNS/Designee at the QA meetings monthly x3 months, then quarterly in order to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. The director of nursing is responsible for the correction and completion of this deficiency. |