Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor food preferences for two residents, both of whom had communicated specific dietary needs and dislikes. One resident with diabetes mellitus, who was on a special diet, had requested to avoid bread, pasta, and desserts due to their impact on blood sugar levels, but continued to receive these items on her meal trays. Another resident expressed a dislike for broccoli and cauliflower but continued to receive these vegetables in her meals. Both residents had intact cognition and had communicated their preferences to staff, but these preferences were not consistently reflected in their menu tickets or the facility's dietary records. Observations and interviews revealed inconsistencies between the posted menus and the actual food served, with substitutions being made due to unavailable ingredients. Residents reported that the posted menus were not always followed, and they were not regularly given choices or asked about their food preferences. The facility's policy required that food preferences be identified and honored, with alternatives offered when residents refused certain foods, but this was not consistently implemented. Staff interviews indicated that food preferences were supposed to be collected upon admission, quarterly, and as needed, with changes communicated through clinical meetings and entered into a computer system. However, there were gaps in communication and documentation, as some staff were unaware of specific resident preferences, and the meal tracking system did not always account for dislikes in mixed vegetables. The Registered Dietitian and Account Manager did not consistently visit residents to update preferences, and the process for updating and honoring food preferences was not reliably followed.