Failure to Provide Meals According to Resident Preferences Due to Incomplete Meal Ticket Process
Penalty
Summary
A deficiency occurred when a resident with dementia, depression, and Parkinson's disease did not receive meal items according to her stated preferences. The resident's meal ticket for lunch was found to be blank, despite her son assisting her in completing it with the help of nursing staff over the phone. The resident reported that this issue had been ongoing since her admission, resulting in her receiving and not eating food she did not order. Observations confirmed that the resident's son questioned the registered dietitian about the blank meal ticket, and the dietitian was unable to explain why the completed ticket was missing. Staff interviews revealed that both nursing and dietary staff were involved in the meal ticket process, but there was a lack of clarity and follow-through regarding the completion and verification of meal tickets. The dietary staff would serve the main dish when tickets were blank, and there was no consistent process to ensure that incomplete tickets were identified and addressed. The nutrition care plan for the resident indicated she was at nutritional risk and required monitoring of meal intake, but the failure to ensure her meal preferences were honored led to the deficiency.