Delayed Meal Delivery in West Rooms 374-387
Penalty
Summary
The facility failed to deliver meals in a timely manner for residents in West Rooms 374-387. According to the facility's tray schedule, lunch was supposed to start at 11:00 a.m., with the specific cart for West 2 (Rooms 374-387) scheduled for 12:05 p.m. However, during an observation on January 21, 2025, it was noted that the lunch trays did not arrive until 12:32 p.m., which was 27 minutes later than scheduled. This delay was confirmed by Nurse Aide Employee E20 and Registered Nurse Employee E21, who both acknowledged the late arrival of the trays. The Registered Nurse indicated that the variability in tray arrival times was due to recent changes in management and the loss of multiple dietary personnel. The Director of Nursing confirmed the facility's failure to deliver meals on time during one of the two meal observations conducted. This deficiency was noted under the regulatory requirements for meal frequency and timing, as well as under Pennsylvania Code sections related to management and resident rights.
Plan Of Correction
There were no negative outcomes noted. Dietary staff will be educated by the Dietary Manager on assuring all the items for the tray line are collected 15 min ahead of the start time of the meal. Dietary supervisors will audit the timeliness of meals daily for 2 weeks, then bimonthly. All results will be reviewed through QAPI for further recommendations. On 2/25/25, the Dietary Manager reeducated ALL dietary staff on what time trays are to be expected to arrive on each unit. All Dietary staff will be educated by the Dietary Manager on ensuring all items for the tray line are prepped 15 min ahead of the start of the meal. The Dietary supervisor will audit the timeliness of meals daily for 2 weeks, then 2x a week for 2 weeks, then bimonthly until substantial compliance is met. All results will be reviewed through QAPI for further recommendations.