Delayed Meal Service Resulting in Resident Distress
Penalty
Summary
During a lunch meal observation, three residents did not receive their meal trays in a timely manner, despite the facility's posted lunch times of 11:30 to 11:45 AM. The dining area had 12 residents waiting, but the meal cart did not arrive from the kitchen until 12:00 PM. While most residents received their trays and began eating, three residents were left without meals. One resident became restless and vocalized frustration about repeated late meal deliveries, another resident wandered the dining room in her wheelchair and had to be redirected by staff, and the third resident remained quiet but appeared bored. The trays for these three residents were delivered significantly late, with the last tray arriving at 12:31 PM, well after the scheduled meal time. The DON confirmed the late delivery of the trays and explained that a misunderstanding in the kitchen led to one tray being sent to a resident's room instead of the dining area. The facility's Meal Distribution Policy requires timely and accurate delivery of meals, with nursing staff responsible for verifying meal accuracy and timeliness. The failure to deliver meals on time resulted in residents experiencing delays, distress, and dissatisfaction during the lunch period.
Plan Of Correction
The facility ensures that resident rights are met, including but not limited to providing timely meals. Residents #5, #37, and #47 receive their meals in a timely manner. Meal service for all three meals was audited on 3/17/25 by the Dietary Manager to monitor timeliness and identify any concerns. Nursing and Dietary Staff were re-educated prior to 4/7/25 by the DON and Dietary Manager, regarding survey results including but not limited to the residents' right to timely meal service, meal service policy, and mealtime guidelines. Management staff complete both formal and informal rounds and report any concerns. The Dietary Manager or designee will conduct weekly audits to review the timeliness of meals. These audits will be completed weekly for 4 weeks, then monthly. Any identified areas of concern will be immediately corrected. Results of the audits will be taken to the QAPI Committee for review and recommendation, and for the determination of continued monitoring. The Dietary Manager will be responsible for monitoring sustained compliance.