Failure to Promptly Resolve Grievance Regarding Vegetarian Diet
Penalty
Summary
The facility failed to promptly resolve a grievance related to a resident's request for a vegetarian diet. The resident, who had diagnoses including hypothyroidism, gastro-esophageal reflux disease, and hypertension, was admitted with a physician's order for a regular vegetarian diet. Despite this, the clinical record and care plan did not reflect the resident's dietary preference, and the quarterly dietary assessment did not mention the need for a vegetarian diet. The resident and her family repeatedly expressed dissatisfaction with the vegetarian food options and preparation, with the family even providing plant-based protein due to ongoing issues. Interviews revealed that the Dietary Manager was aware of the resident's vegetarian preference within 24 hours of admission and provided available vegetarian items, but this information was not incorporated into the resident's clinical record or a multidisciplinary care plan. The dietary department lacked access to the electronic clinical record, further hindering coordinated care. The resident reported that meals often consisted of repetitive items like eggs, dairy, and peanut butter, and that food brought in by her family was sometimes improperly prepared by staff. Documentation and interviews indicated that the resident's family had communicated their concerns to multiple facility leaders, including the Administrator and DON, without resolution for an extended period. The Ombudsman confirmed that the issue persisted since admission and that the facility, resident, and family were unable to resolve the concern until a care plan meeting was eventually held. The facility's grievance policy required prompt review and resolution of complaints, but this was not achieved in the resident's case.