Failure to Serve Meals at Palatable Temperatures Due to Delayed Assistance and Poor Communication
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures for a resident who required assistance with eating and in the kitchen overall. One resident, admitted with a history of stroke and heart disease and assessed as cognitively intact but needing supervision for eating, was observed waiting in bed with a meal tray while her food became cold. Staff interviews revealed that the resident often received meals at her bedside without timely assistance, leading to cold food. The resident's care plan indicated a need for one-person assistance with meals, but this requirement was not reflected on the diet slip or meal ticket, resulting in communication lapses among staff. Staff acknowledged that meal assistance needs were not consistently communicated or documented, and that this contributed to delays in providing timely and warm meals. Additionally, observations showed that meal carts were left unattended and that staff did not always promptly distribute meals. A test tray left in a food cart for 22 minutes was found to have cold broccoli and lukewarm potatoes and meat, confirming that food was not maintained at appetizing temperatures. Staff interviews indicated that there was an expectation for all staff, including nurses, to assist with meal distribution, but this was not consistently practiced. The lack of clear communication, documentation, and timely staff response led to residents receiving food that was not palatable or at a safe and appetizing temperature.