Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to their preferences, as evidenced by the experiences of two residents. Resident 2, who has a diagnosis of anxiety and hypertension, was served a lunch that included buttered carrots, despite her meal tray ticket indicating a dislike for carrots. The resident confirmed that she was not offered a substitute and often received items she did not prefer. This incident was observed on January 3, 2025, and the resident was alert and oriented at the time. Similarly, Resident 3, who has heart failure and diabetes, was served lemonade with his meal, even though his meal ticket specified that he disliked lemonade. The resident, who was also alert and oriented, confirmed that he frequently received lemonade despite his stated preference. The dietary department was expected to follow the residents' preferences as identified on the meal tickets, but this was not adhered to in these cases.
Plan Of Correction
Facility provided re-education to the dietary staff on following food preferences listed for residents. NHA/Food Service Director will review job functions of the dietary tray line with the tray line staff. Re-education will include having last person on the tray line double checking items on tray against items listed on preferences. NHA/Designee will conduct audits 3 times a week for 2 weeks, then weekly for 4 weeks to ensure residents are being served items according to their listed preferences. All results will be reported to the QAPI Committee.