cms_UT: 18
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 18 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 810 | E | 0 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide special eating equipment and utensils for residents who need them. Specifically, 1 of 41 sample residents did not receive a weighted spoon in accordance with physician's orders [REDACTED]. Findings include: Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 12:15 PM, an observation was made of resident 28 during lunch service. Resident 28 was observed to scoop ground meat onto her fork and attempted to bring the fork to her mouth. Resident 28 was observed to visibly shake and struggled to guide the fork to her mouth, and the ground meat fell off of her fork and onto her lap. Resident 28 was then observed to use her hands to eat the remainder of the meal. (Note: Resident 28's silverware was not weighted.) On 2/20/19 at 12:16 PM, a follow up observation was made of resident 28 during lunch service. Resident 28 was observed to cut a piece of pie into smaller pieces using a spoon. Resident 28 was then observed to eat each bite of pie and a bowl of diced fruit with her hands. (Note: Resident 28's silverware was not weighted.) On 2/20/19, resident 28's physician orders [REDACTED]. a. Order: FORTIFIED diet, MECHANICAL SOFT - Chopped texture, HONEY THICK consistency b. Directions: scoop plate, SIPPY CUP, POSITION FULLY UP RIGHT, x (extra) -SAUCE/GRAVY TO MEAT WHEN APPLICABLE. Finger food as able. AM (morning) snack coffee & (and) health shake. WEIGHTED SPOON. Health shake TID (three times per day) with meals. Cheeseburger w/ (with) fries Q (every) L (lunch) & D (dinner) non ground hamburge (sic) On 2/20/19, resident 28's Registered Dietitian notes were reviewed. The notes documented the following information: a. 10/4/18; Diet: FORTIFIED MECHANICAL SOFT - Chopped texture, HONEY THICK consistency, scoop plate, SIPPY CUP, POSITION FULLY UPRIGHT . WEIGHTED SPOON . b. 3/15/18; Diet: FORTIFIED MECHANICAL SOFT, HONEY THICK consistency, PLATE GUARD, SIPPY CUP, POSITION FULLY UPRIGHT . WEIGHTED SPOON . c. 3/1/18; Diet: FORTIFIED MECHANICAL SOFT, HONEY THICK consistency, PLATE GUARD, SIPPY CUP, POSITION FULLY UPRIGHT . WEIGHTED SPOON . On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated residents who had [MEDICAL CONDITIONS], or experienced a stroke were examples of those who may have required weighted silverware. CNA 1 further stated she had no idea if resident 28 required weighted silverware and would have notified the nurse, speech therapist, restorative aide, and dietitian if she noticed resident 28 struggling to eat her meal. On 2/21/19 at 10:12 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated weighted silverware was typically prescribed for residents whose hands shake. The RD further stated resident 28 should have received a weighted spoon with her meals, and confirmed that the physician order [REDACTED]. On 2/21/19 at 11:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 28 should have received weighted silverware and it was missed by the staff. | 2020-09-01 |