Meal Left Unattended for Dialysis-Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a meal was served at a palatable temperature for a resident who was dependent on renal dialysis and had multiple medical conditions, including congestive heart failure, ischemic cardiomyopathy, type II diabetes, and end stage renal disease. The resident's lunch tray was delivered and left on her bedside table while she was away at dialysis. Observations confirmed that the tray remained on the bedside table for several hours, from the time it was delivered until the resident returned from dialysis and ate the meal. The resident reported that she was hungry upon her return and asked staff to heat up her meal, but staff did not do so. Interviews with staff revealed that it was common practice to leave the meal tray in the resident's room so she could eat upon her return, although the Dietary Manager stated that trays should not be left out and should instead be returned to the kitchen for proper storage. The tray, which included a tamale and black beans, was ultimately consumed by the resident after it had been sitting out for more than two hours, as confirmed by a CNA who removed the tray afterward.