Resident Missed Meal Due to Inadequate Meal Service System
Penalty
Summary
The facility failed to ensure that all residents received their meals as required, resulting in one resident not being served lunch while others at her table were eating. During the lunch service, staff were observed serving meals in a random order, and a resident with a mechanical soft diet and a history of significant weight loss was left without food for an extended period. Despite having a meal ticket indicating her dietary needs, the resident repeatedly stated she had not received her meal and appeared visibly upset and hungry. It was only after another resident alerted staff that the oversight was addressed. The affected resident had multiple medical diagnoses, including moderate protein-calorie malnutrition, heart disease, and dysphagia, and was at risk for fluctuating weights as documented in her care plan. The facility's policy required staff to ensure all components of the meal matched the diet card and resident preferences, but this process was not followed, leading to the resident missing her meal. Staff interviews confirmed the failure to serve the meal and acknowledged the lapse in the meal service system.