Failure to Meet Resident Dietary Preferences
Penalty
Summary
The facility failed to meet the dietary preferences and needs of two residents, leading to a deficiency in providing food that accommodates resident preferences. Resident #66, who has a moderate cognitive impairment as indicated by a Brief Interview of Mental Status score of 11, was observed during two separate dining occasions to have discrepancies between the meal ticket and the food served. On one occasion, the resident's meal did not include mashed potatoes as requested, and the soft cooked parslied potatoes had skin, which the resident did not want. On another occasion, the resident's meal was missing the ground beef cubes in gravy that were listed on the meal ticket. Similarly, Resident #57, who has no cognitive impairment as indicated by a Brief Interview of Mental Status score of 15, experienced a discrepancy in their meal service. The resident's meal ticket included a large salad with chicken and a Kens salad, neither of which were provided on the tray. The dietary manager/director of food services acknowledged the issue, stating that there are two checkpoints in place to ensure meal tickets match the trays, but these were not effective in preventing the errors observed.
Plan Of Correction
F806 RESIDENT, PREFERENCES, SUBSTITUTES 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #66, not meeting the residents' preference for food, the resident's tray tickets did not match the food on the tray. Dietary staff will be in-serviced to follow the tray tickets. 2) In the allegation of Resident #57, not meeting the residents' preference for food, the resident's tray tickets did not match the food on the tray. Dietary staff will be in-serviced to follow the tray tickets. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Dietary staff will be in-serviced to follow the tray tickets. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Dietary Manager or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date: