Failure to Provide Nourishing Snacks at Non-Traditional Times
Penalty
Summary
The facility failed to provide suitable and nourishing snacks to eight out of nine residents who expressed a desire to eat at non-traditional times, outside of the scheduled meal service. This deficiency was identified through clinical record reviews, interviews with residents and staff, and reviews of policies and procedures. The facility's policy required that bedtime snacks be placed within reach of each resident and that nursing staff assist residents with eating these snacks as necessary. However, during a group meeting, residents reported that they were not routinely offered nourishing snacks at bedtime, despite being able to express their nutritional preferences and needs. Observations revealed that bulk snacks were provided by the dietary department at 6:00 a.m. for use during the 7-3 shift, but there was no consistent documentation or assurance that the 3-11 shift staff offered bedtime snacks to all residents. Clinical records for the involved residents, who were mostly cognitively intact, showed a lack of consistent documentation indicating that staff were completing the task of offering and assisting with bedtime snacks. Additionally, food committee meeting minutes noted a resident's concern about not being frequently offered between meals and bedtime snacks as care planned.
Plan Of Correction
1. On 12/19/2024 the DON assessed Residents R111, R23, R476, R95, R145, R133, R162 and R167 and there were no negative outcomes. On 12/19/2024 the Dietary department delivered HS snacks to all units. 2. On 12/19/2024 the dietician reviewed the electronic records of residents identified as "at risk" for weight loss to verify that nourishment orders were in place if necessary. 3. The dietary department will deliver nourishments 3 times per day for residents with orders and re-stock the units with nourishments for all other residents daily. A nourishment log will be utilized to verify the nourishment delivery. 4. On 12/19/2025 the NHA and Dietary Manager educated the dietary staff, providing nourishments between meals. 5. The NHA/designee will conduct audits of nourishment delivery 3x per week for 4 weeks and monthly for 3 months.