Failure to Provide Bagged Lunch for Dialysis Resident
Penalty
Summary
A deficiency occurred when a resident with stage 5 chronic kidney disease, who was admitted for short-term rehabilitation and required outpatient dialysis three times a week, was not provided with a bagged lunch on the days of her dialysis treatments. The resident reported that she left the facility for dialysis after having breakfast in the morning and returned in the late afternoon, expressing that she was very hungry upon return as no lunch was provided. The facility had a process in place where the dietary department prepared bagged lunches for dialysis days, and nursing staff were responsible for retrieving and sending the lunch with the resident. Despite this process, the assigned nurse aide admitted to forgetting to collect and send the bagged lunch with the resident on two separate occasions. The dietary manager confirmed that the lunches were prepared and available in the kitchen on those days, but was unaware that they were not delivered to the resident. The medical director and administrator both acknowledged that a bagged lunch should have been provided to the resident on dialysis days.