Failure to Provide Well-Balanced Diets and Honor Food Preferences
Penalty
Summary
The facility failed to provide a well-balanced diet that met the nutritional needs and honored the food preferences of two residents. One resident, who had a history of acute and chronic respiratory failure, COPD, and pneumonia, was not identified as a vegetarian in his food preference or nutrition assessment forms. As a result, he was repeatedly served meals that did not align with his dietary needs, including being given potato chips as a main dish and lacking adequate protein variety. The registered dietitian was unaware of the resident's vegetarian status until informed by the surveyor, and the kitchen manager acknowledged that there was no specific diet for lacto-ovo-vegetarians, despite having discussed preferences with the resident multiple times. Another resident, admitted with intervertebral disc displacement and on a carbohydrate-controlled, no added salt diet, reported that his meals were consistently overcooked, burnt, and of poor quality. He provided photographic evidence of inedible meals, including being served only potato chips as an entrée when the main dish included pork, which he could not eat for religious reasons. The resident stated that he had repeatedly voiced his concerns to the Certified Dietary Manager (CDM), but the issues persisted and were not resolved. The CDM acknowledged the resident's complaints and confirmed that the meal ticket system failed to capture his need for a pork-free alternative entrée. Both residents were cognitively intact and able to clearly communicate their dietary needs and dissatisfaction with the meals provided. Despite their repeated efforts to address these concerns with dietary staff, the facility did not ensure that their nutritional needs and food preferences were consistently met, resulting in inadequate and inappropriate meal service.