Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to provide meals in accordance with a resident's documented food preferences. The resident, who had diagnoses including diabetes, end stage renal disease, and major depressive disorder, was cognitively intact and required set up assistance with meals. Documentation in the Nutrition Data Collection/Evaluation and Meal Tracker printout indicated that carrots were listed as a dislike for this resident, and the resident's diet was updated accordingly. Despite this, photographic evidence provided by the resident's family showed that carrots were repeatedly served to the resident, even when tray tickets specified other vegetables such as brussel sprouts, whole kernel corn, or broccoli florets. Interviews with the resident's family and facility staff, including the District Director of Dietary and the DON, confirmed that the resident received food items listed on her dislike list for at least three meals. The facility's policy required that individual tray assembly tickets reflect all food items appropriate for the resident based on diet order, allergies, intolerances, and preferences. Both the Regional Director of Dietary and the DON reviewed and verified the photographs, confirming the discrepancy between the resident's documented preferences and the meals served.