Failure to Serve Lunch Meals at Scheduled Times Due to Kitchen Malfunction
Penalty
Summary
The facility failed to provide lunch meals to 196 out of 216 residents at the scheduled mealtime, as required by facility policy and posted meal schedules. On the day in question, the kitchen oven thermostat and igniter malfunctioned, causing the kitchen staff to begin plating lunches an hour late. As a result, the first lunch trays did not leave the kitchen until 1257 hours, well after the scheduled lunch period of 1130 to 1230 hours. The Dietary Manager confirmed that all residents receiving kitchen-prepared meals would not receive their lunch within the scheduled timeframe, which was important for those with medications scheduled around meal times. Multiple residents reported not receiving their lunch at the expected time, expressing feelings of hunger, frustration, and aggravation. One resident, who had received six units of insulin at 1130 hours, had not received her lunch by 1320 hours and reported feeling sweaty and hungry, requiring juice and a snack from staff. Nursing documentation confirmed her blood sugar was rechecked due to the late meal. Other residents also reported not being informed about the delay and described significant hunger, with one rating their hunger as a nine out of ten. These observations and interviews confirm that the facility did not meet its obligation to serve meals at scheduled times according to residents' needs and preferences.