Failure to Provide Timely and Dignified Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for three residents by not ensuring timely meal service. During the lunch period, three staff members were observed receiving lunch trays before all residents had been served, contrary to facility policy. Observations and interviews revealed that some residents remained in their rooms without having received their meals well after lunch service had begun. One resident, who was dependent on staff for all activities of daily living and unable to speak due to medical conditions including Huntington's disease and aphasia, was observed expressing hunger and did not receive a meal until over two hours after lunch service started. Another resident with moderate cognitive impairment and a third resident with intact cognition both reported being hungry and not having received their lunch during the observation period. Staff interviews confirmed that the affected residents had not yet received their meals due to staff being occupied with other residents. The Director of Nursing and Dietary Manager both acknowledged that staff should not receive meals before all residents are served, and the facility's policy requires prompt delivery of food to ensure safe, palatable, and high-quality meals. The failure to follow this policy resulted in residents experiencing frustration and helplessness while waiting for their meals.