Failure to Provide Identifiable Pureed Foods and Inform Residents of Meal Contents
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence and self-determination by not serving identifiable foods to two residents on pureed diets. In both cases, meal tickets did not specify the food items being served, and staff members assisting with feeding were unable to identify the pureed foods on the residents' trays. Staff expressed uncertainty about the contents of the meals and acknowledged that they would not be able to inform residents or their families about what was being served, nor could they confirm the absence of allergens. One resident with Alzheimer's disease, severe protein-calorie malnutrition, dysphagia, and adult failure to thrive was observed being assisted with meals where neither the assisting staff nor the dietary manager could identify the pureed food items. The menu for the day listed specific items, but these were not reflected on the meal ticket or easily identifiable on the plate. Staff confirmed that the meal ticket lacked information about the food items, and the dietary manager verified the unidentified foods after checking in the kitchen and with the resident's tray. Another resident with COPD, hypertension, dysphagia, and anemia, who was cognitively intact, reported eating the same foods daily and not being offered alternatives. This resident was observed eating only oatmeal, stating that the other pureed items were unidentifiable and unappealing. The dietary manager was also unable to immediately identify the foods served and confirmed that one item (sausage) was not on the menu. Facility policies reviewed indicated that residents' preferences should be assessed and that they should be informed about their meals, but these practices were not followed.