Failure to Provide Meals According to Resident Preferences
Penalty
Summary
The facility failed to provide meals that met the preferences and dietary requirements of two residents, leading to deficiencies in their care. Resident #78, who has a severe cognitive impairment and a diagnosis of malignant neoplasm of the lower respiratory tract, was observed to have missing items on their meal tray, including margarine, syrup, and gravy, which were listed on their meal ticket. This oversight occurred despite the presence of a system where two staff members are responsible for checking meal tickets and trays. Similarly, Resident #77, who has mild cognitive impairment and a diagnosis of benign intracranial hypertension and diabetes mellitus with hyperglycemia, received a meal tray that was missing one slice of bacon, contrary to the meal ticket specifications. The kitchen manager acknowledged the errors in both cases, indicating a lapse in the facility's meal preparation and delivery process, which failed to ensure that residents received meals according to their documented preferences and dietary needs.