Failure to Meet Residents' Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide meals that met the dietary preferences, allergies, and intolerances of four residents during dining observations. Resident #56, who has severe cognitive impairment, did not receive the fortified mashed potatoes listed on their meal ticket. Resident #15, with no cognitive impairment, was missing ice cream from their meal tray. Resident #118, also with no cognitive impairment, expressed frustration over consistently receiving green vegetables, which they had explicitly stated they disliked. Resident #368, newly admitted and without a completed Minimum Data Set, reported that their food preferences were not considered, receiving items they do not consume, and described the food as inedible and served cold. The facility's meal distribution process was observed to have multiple checkpoints intended to ensure meal tickets match the trays, involving aides and nurses. However, during observations, it was noted that the Licensed Practical Nurses (LPNs) distributing the trays did not uncover the plates to verify the food consistency against the meal tickets. Despite the District Manager's assertion of a thorough checking process, discrepancies in meal delivery were evident, as seen in the cases of the residents mentioned. Interviews with staff revealed inconsistencies in the meal distribution process. Staff B, an LPN with over 11 years of experience, claimed to check the meal tickets and uncover plates to verify consistency, yet observations contradicted this. Similarly, Staff A, another LPN, admitted to not uncovering plates during distribution, relying on Certified Nursing Assistants to report inconsistencies. These lapses in procedure contributed to the failure in meeting residents' dietary needs and preferences, as documented in the survey findings.
Plan Of Correction
Boca Circle Rehabilitation Center failed to provide food that meets residents' preferences and intolerances. **Actions Taken:** 1) Resident #56 was seen by the Registered Dietician on and remains in the facility in stable condition. Resident #15 was seen by the Registered Dietician on and remains in the facility in stable condition. Resident #118 remains in the facility in stable condition. Resident was seen by the Registered Dietician on and food preferences have been updated. Resident #368 remains in the facility in stable condition. Resident was seen by the Registered Dietician on and food preferences have been updated. Staff A, LPN was reeducated on verifying plated food matches residents' meal ticket on by Ellie Schutt, LNHA. Staff B, LPN was reeducated on verifying plated food matches residents' meal ticket on by Ellie Schutt, LNHA. Staff D, LPN was reeducated on verifying plated food matches residents' meal ticket on by Ellie Schutt, LNHA. **Others Identified:** 2) A facility audit was conducted by the Dietary Manager/Designee on to ensure provision of food to meet residents' preferences and intolerances. Residents' dietary preferences were updated as indicated. **Measures Taken:** 3) Dietary Staff were in-serviced on ensuring the residents' diet preferences are honored including condiments on by CDM. Education for Licensed Nurses and CNAs was initiated on regarding checking the meal tickets and meal tray for correct consistency by DON/Designee. Newly hired dietary and nursing staff will receive this education during general orientation. **Ongoing Monitoring:** 4) Dietary Manager/Designee will conduct audits 5x/week to verify that residents' dietary preferences are correct and Licensed Nurses are checking meal trays for correct consistency x 4 weeks, and then every week x 4 weeks, followed by weekly x 1 month. Audit results will be reviewed in Center QAPI meeting until substantial compliance has been met.