Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor food preferences for three residents, resulting in multiple instances where residents received meals that did not align with their documented choices or dietary needs. One cognitively intact resident repeatedly received incorrect meals despite filling out menus and communicating their preferences, including being served barbequed ribs instead of shrimp scampi, scrambled eggs instead of boiled eggs, and fish and rice which they did not eat. Another cognitively intact resident did not receive yogurt and apple juice as indicated on their tray card, and was instead given orange juice and oatmeal. Staff interviews confirmed that residents' menu selections were sometimes lost, not returned to the kitchen in a timely manner, or not accurately transcribed onto meal tickets. A third resident, with moderate cognitive impairment and a diagnosis of failure to thrive, was served foods listed as dislikes on their dietary profile, such as scrambled eggs and potatoes, and was not offered alternatives. Staff acknowledged that meals were often returned to the kitchen due to incorrect orders, and that inconsistencies existed between menu selections and tray card information. The dietary manager noted that issues could arise from hurried or inexperienced kitchen staff, or from lapses in the menu collection process. These failures were observed through direct resident statements, meal observations, and staff interviews.