Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor residents' meal preferences as required, affecting nine out of ten residents reviewed for this issue. Record reviews showed that residents had documented dietary preferences, such as not receiving bread or rolls, requesting extra gravy, or wanting gravy on the side. Despite these documented preferences, observations during a lunch meal revealed that several residents did not receive meals according to their stated preferences. For example, some residents received bread or rolls when they should not have, did not receive extra gravy as requested, or received gravy when they had requested none or to have it on the side. These findings were confirmed by staff interviews at the time of meal service. Additionally, interviews with three residents indicated that meal preferences were not consistently honored, and review of the facility's policy confirmed that dietary preferences should be accommodated if requested. The affected residents had a range of medical conditions, including severe cognitive impairment, dementia, depression, diabetes, kidney disease, and dysphagia, with varying levels of assistance required for eating. The deficiency was identified during a complaint investigation and was supported by direct observation, record review, and staff and resident interviews.