Failure to Provide Complete Meal per Resident's Dietary Needs
Penalty
Summary
A deficiency occurred when a resident did not receive all the food items listed on their meal ticket, specifically the protein portion, during a dinner service. The resident, who was cognitively intact with a BIMS score of 13 and on a regular diet per physician order, received a tray containing mashed potatoes, green peas, and sliced bread, but no protein. The resident reported this to staff and requested an alternative (a peanut butter and jelly sandwich), but did not receive it. The Food Service Manager was unable to provide a clear reason for the omission and confirmed that the meal ticket indicated the resident should have received chicken as the protein. Further investigation revealed that the resident had a known dislike for beef due to difficulty digesting it, but did not have a dislike for pork and typically received fish as a substitute when needed. The Food Service Manager acknowledged familiarity with the resident's dietary preferences but could not explain why the protein was omitted from the meal. The omission was attributed to being overlooked, as confirmed by review of the meal ticket and staff interviews.