Failure to Provide Menus and Follow Prescribed Diets for Residents
Penalty
Summary
The facility failed to provide menus and ensure nutritional adequacy for three residents by not supplying meal menus in advance, not following prescribed meal portions, and not honoring food preferences as documented in care plans and physician orders. For one resident with multiple diagnoses including diabetes, end stage renal disease, and chronic kidney disease, the facility did not provide the ordered double portion and fortified oatmeal for breakfast, resulting in the resident waiting over two hours for the correct meal and being unable to take morning medications due to an empty stomach. Observations and interviews confirmed that the resident's meal ticket specified double portions and oatmeal, but these were not delivered as ordered. Another resident, dependent on staff for most activities of daily living and at nutritional risk due to wound healing needs, reported never receiving a menu and not being informed about meal options. This resident expressed dissatisfaction with the food, was not offered substitutions, and often ate less than 25% of meals, leading to persistent hunger. Staff interviews confirmed that menus were not distributed to residents and that communication about meal options was lacking, especially for those who were bedbound or did not attend the activity room. A third resident, with significant medical history including diabetes with neuropathy and multiple amputations, also did not receive a menu and was not informed about meal options. This resident frequently found the meals unappetizing and insufficient in portion size, often resorting to limited substitution options such as a cold turkey sandwich. Staff and dietitian interviews corroborated that menus were only posted in common areas and not provided individually, making it difficult for residents, especially those confined to their rooms, to make informed meal choices or request timely substitutions. Facility policies required that food preferences be honored and menus be reviewed with residents, but these practices were not followed.