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Issue Cited:
“Offering/Serving Bedtime Snacks on a Daily Basis”
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also
not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this
response and plan of correction. This plan of correction is submitted as the facility’s credible allegation of compliance.
1. Immediate action(s) taken for the resident(s) found to have been affected include:
Nursing and Dietary Services were immediately in-serviced on our standard of practice (SOP) for
offering and serving bedtime snacks.
2. Identification of other residents having the potential to be affected was accomplished by:
The facility has determined that all residents have the potential to be affected.
3. Actions taken/systems put into place to reduce the risk of future occurrence include:
All nursing and dietary staff have been in-serviced on the facility’s “Offering/Serving Bedtime
Snacks” policy and standard of practice. In-service training included observation of individuals
performing the procedure. A “Validation Checklist” was completed for each individual observed to
determine if the individual was performing the procedure in accordance with our SOP. Findings
were reviewed with each individual observed. Corrective action was provided as needed.
4. How the corrective action(s) will be monitored to ensure the practice will not recur:
The Director of Nursing Services (DNS), or designee, will complete random weekly audits of staff
offering/serving bedtime snacks for six (6) consecutive weeks. Random verification checklists will
be completed to ensure that bedtime snacks are being offered in accordance with our policy and
standard of practice (SOP).
Audit records and validation checklists will be reviewed by the Risk Management/Quality Assurance
Committee until such time consistent substantial compliance has been achieved as determined by the
committee.
Audit results will be shared with the Resident/Family Group Council for comment and suggestions.
Corrective action completion date: _________________________.
Policy Offering/Serving Bedtime Snacks
Offering/Serving Bedtime Snacks
Date Implemented: Date Reviewed/Revised: Reviewed/Revised By:
Standard:
It is the practice of this facility to offer and serve residents with a nourishing snack at bedtime on a
daily basis.
1. The nursing staff offers bedtime snacks to all residents on a daily basis.
2. All diabetic or special diet bedtime snacks are labeled and dated. Each label contains the
resident’s name and room number.
3. Dietary services delivers bedtime snacks to each nurses’ station. The Charge Nurse is made aware
of the delivery of the snacks.
4. Nursing staff delivers and serves snacks to residents in accordance with our standard of practice
(SOP) entitled Offering/Serving Bedtime Snacks.
5. Inquiries concerning this policy should be referred to the Director of Nursing Services (DNS)
who may be reached by calling ____________________________ or by dialing extension
____________.
Standard of Practice (SOP/Checklist) Offering/Serving Bedtime Snacks
Standard of Practice (SOP)
Offering/Serving Bedtime Snacks
Why You Do It :
The reason for offering bedtime snacks is to provide residents with adequate nutrition.
Write It Down:
Document:
1. The date and time you served the snack.
2. Your name and position title.
3. The amount of the snack eaten (e.g., 25%, 50%, 75%, 100%).
4. If the resident refused the snack and why, and any food substitutes offered or interventions taken.
5. Other information as indicated or appropriate.
Report:
1. If the resident refused the snack and why.
2. Chewing/swallowing difficulties, skin conditions, complaints, etc.
Standard of Practice (SOP/Checklist) Offering/Serving Bedtime Snacks
Standard of Practice - Validation Checklist
Offering/Serving Bedtime Snacks
Purpose: To determine if the individual offering or serving the bedtime snack is doing so in accordance with the
facility’s standard of practice. Record observations below. Review findings with the individual being observed. Provide
corrective action as needed.
Satisfactory
# Procedure Observed Comments
Y N NA
1 Reviewed care plan.
2 Washed hands.
3 Followed RR protocol (e.g., knocked on door, maintained privacy, etc.)
4 Offered the resident a bedtime snack.
5 Checked tray to ensure right resident and right diet.
6 Placed snack track on overbed table / serving area.
7 Described snack to resident.
8 Assisted resident to comfortable position (as necessary)
9 Placed napkin. Opened beverage containers, straws, etc. (as necessary)
Assisted resident with snack (as necessary). Encouraged resident to feed
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self as much as possible.
11 Positioned call light device within easy reach of resident.
12 Allowed resident ample time to finish snack.
13 Removed snack tray and offered resident wash cloth.
14 Cleaned and stored overbed table.
15 Assisted resident to bed (as applicable/requested by resident)
16 Repositioned bed covers. Assisted resident to comfortable position.
17 Placed call-light device within easy reach of the resident.
Followed IC protocol (e.g., washed hands, use of PPE, discarded soiled
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items into appropriate containers etc.).
19 Recorded/Reported appropriate data.
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Instructions: Randomly select a floor/hall/wing to observe the offering and serving of bedtime snacks. Observe staff performing the procedure. Record responses below. Record
additional information in the “Comments” section. Provide completed report to the Risk Management/QA Committee. Use additional copies of this form as necessary.
(Abbreviations: SOP = Standard of Practice; NS = Nurses’ Station).
Observations
Snack Snack SOP
Resident Observed Comments
Offered Served Followed
Y N* Y N* Y N **
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The following personnel attended the Offering/Serving Bedtime Snacks in-service training
program conducted on _____________________________.
License Number
Printed Name Signature
(as applicable)
Time Ended: