Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor the dietary preferences of a resident, identified as Resident 59, by serving fish, a food the resident dislikes, during lunch on February 28, 2025. This incident was observed during a concurrent observation and interview with the resident, who confirmed the presence of fish on their plate despite their known dislike for it. The resident's dietary profile, updated on January 29, 2025, clearly indicated a dislike for fish, and the meal ticket for that day also reflected this preference. However, the meal ticket was not adhered to, resulting in the resident being served fish. Interviews with the Dietary Supervisor and Certified Nursing Assistant (CNA) 6 revealed that the kitchen staff was aware of the resident's dietary preferences and intolerances, and the meal ticket system was in place to prevent such errors. Despite this, the oversight occurred, and the Dietary Supervisor acknowledged that multiple staff members failed to notice the error. The Director of Nursing expressed concern that serving a disliked food could lead to psychosocial issues and potential weight loss for the resident. The facility's policy emphasizes respecting residents' dietary choices and ensuring their nutritional needs are met, but this incident demonstrated a lapse in following these guidelines.
Plan Of Correction
A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 59 is receiving his meals per his choices and preferences. The Dietary Services Supervisor completed a Food Preference Evaluation to identify Resident 59's food likes and dislikes to ensure Resident 59 is served meals according to his preference on 2/28/2025. The Dietary Service Department updated Resident 59's tray card with his current food likes and dislikes to ensure he is served meals according to his preferences. The Dietary Services Department updated Resident 59's tray card with his current food likes and dislikes to ensure he is served meals according to his preferences. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents not receiving meals per their preferences are potentially affected. The Social Service Director audited resident grievances from January 1 through February 28th, 2025, to identify grievances related to meal service on 3/17/2025. The Activities Director audited the last two months of Resident Council minutes to identify any grievances related to meal service on 3/17/2025. No other residents were identified as having concerns related to meal service and food preferences. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Dietary Supervisor completed dietary competency evaluations of the cooks and meal service staff on 3/13/2025 to ensure the cooks and meal service staff prepare the resident's meal tray per their documented meal ticket preferences. The Dietary Supervisor will implement the use of the CAHF Meal Accuracy Report once weekly to identify meal service accuracy concerns and report findings to the Quality Assurance Committee for improvement beginning December 2025. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Registered Dietitian will, as part of the routine kitchen audit, monitor meal service to ensure meals are prepared in accordance with the physician order and the cook has the appropriate skills and competency to prepare the resident meals. This will be done twice a month, and the RD will utilize the CAHF Food & Nutrition Meal Tray Accuracy - Quality Assurance Report. The IDT, including the RD, will monitor resident weight monthly to identify residents with unplanned weight loss and determine the root cause of the weight loss. The Director of Activities monitors the grievances of residents monthly during resident council and will report food-related concerns to the DSS following the resident council meeting for immediate correction. The Director of Social Services will monitor the grievance log for meal preparation concerns and report these concerns to the dietary services department for immediate correction. The Director of Nursing/designee will report trends identified in the dietary feedback audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F812 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The two dented cans in dry storage were removed and placed in the dented can area by the Dietary Manager on 2/24/2025 at the time of observations during the survey to avoid using them for residents, as the seal of the dented cans had already been broken and can release chemicals which can cause cross-contamination. 2. The Dietary Manager removed the box of open, undated graham cookie crumbs. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: 128 residents are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Dietary Services Director will re-educate the dietary staff on or before 3/19/2025 regarding the facility policy and procedures: Dented cans must be removed from the food supply and placed in the dented can area to avoid using them for residents.