Failure to Accurately Implement Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident's dietary preferences were accurately implemented, as required by federal regulations. During observation, a resident was served a breakfast tray that did not match the items listed on their diet slip. Specifically, the tray was missing a Western omelette and yogurt, included scrambled eggs instead of the omelette, and only one cold cereal instead of two. The resident confirmed the discrepancy during an interview. The diet slip is intended to communicate the correct meal components based on the resident's preferences and dietary orders. Interviews with facility staff revealed that the expectation is for food trays to be prepared and checked for accuracy according to the diet slip, which reflects the physician's orders and the resident's preferences. Staff responsible for distributing meal trays are expected to verify that each tray contains the correct items. A review of the facility's policy indicated that individual food preferences are to be assessed upon admission and communicated to the interdisciplinary team, with any modifications ordered with the resident's or representative's consent. Despite these procedures, the resident did not receive the correct meal as ordered.
Plan Of Correction
1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 20 was interviewed by the Food Service Director on whether they were served a diet taking into consideration their preferences and what they received for meals. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Food Service Director or designee in-serviced the dietary department staff on providing meals as ordered that meet resident preferences. The Food Service Director or designee will audit meal trays to ensure the prescribed diet is followed and served, and that the food served meets the resident's preferences. The Food Service Director or designee will interview residents to ensure they receive the correct diet and that their preferences are met. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Resident 20 will be interviewed by the Food Service Director or Designee on whether they have received their meals as ordered weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. The Food Service Director or designee will audit 10 meal trays to ensure the prescribed diet is followed and served and that the food meets the residents' preferences. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. The Food Service Director or Designee will interview 10 residents to ensure they receive the correct diet and that their preferences are met. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.