Failure to Honor Resident Food Preferences Due to Dietary Miscommunication
Penalty
Summary
A deficiency occurred when the dietary services department failed to honor a resident's documented food preferences for dinner on a specific date. The resident, who had conversion disorder, anarthria, and aphonia, was dependent on staff for several activities of daily living and communicated her meal preferences through a written list/menu, which was signed by the Dietary Services Supervisor (DSS). The care plan indicated that dietary staff were to review and provide food according to the resident's preferences, and the resident and DSS had agreed to review and update the menu weekly. On the day in question, the resident only received a strawberry smoothie for dinner, despite having a detailed menu of preferred foods for each meal. Interviews with the DSS and kitchen staff revealed a miscommunication: the cook believed only a smoothie was required, as the DSS had not informed the kitchen to prepare the resident's preferred dinner. The DSS acknowledged the need to provide meals according to the resident's written preferences, and the kitchen staff stated they had not received instructions to prepare anything beyond the smoothie and lemons. The facility's policy required staff to determine and honor resident food preferences and to offer a variety of foods at each meal. However, the failure to communicate and provide the resident's requested meal resulted in the resident's food choices not being honored, with the potential for unmet nutritional needs.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 was seen by the Dietary Supervisor on March 27, 2025, and the dietary preferences were updated to ensure there are no further concerns regarding the residents' meal schedule. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28, 2025, the Dietary Supervisor/designee reviewed resident preferences as documented on individual meal slips to ensure all preferences were current and being appropriately followed. No additional findings were identified as a result of the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 26 to March 27, 2025, the Dietary Supervisor or designee conducted in-service training for dietary staff on the importance of following resident preferences and adhering to the established meal slips. Licensed nurses will report any inconsistencies related to meal slips to the Dietary Supervisor for further review. The Dietary Supervisor will report any negative findings to the Administrator for appropriate follow-up and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. All residents had the potential to be affected by this deficient practice. On March 28, 2025, the Dietary Supervisor/designee reviewed resident preferences as documented on individual meal slips to ensure all preferences were current and being appropriately followed. No additional findings were identified as a result of the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 26 to March 27, 2025, the Dietary Supervisor or designee conducted in-service training for dietary staff on the importance of following resident preferences and adhering to the established meal slips. Licensed nurses will report any inconsistencies related to meal slips to the Dietary Supervisor for further review. The Dietary Supervisor will report any negative findings to the Administrator for appropriate follow-up and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 28th, 2025