Failure to Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when dietary staff failed to honor a resident's documented food dislikes, resulting in the resident being served a salad containing tomatoes, which she disliked. The resident's admission record and meal slip clearly indicated a dislike for tomatoes and carrots, yet her lunch tray included tomatoes. The resident, who had left side hemiplegia and COPD, was observed attempting to remove the tomatoes from her salad and expressed her dissatisfaction, stating she wanted to eat the salad but not with tomatoes. The resident was dependent on staff for most activities of daily living and required setup assistance for eating. Interviews with the Dietary Supervisor, Assistant Director of Nursing, and Director of Nursing confirmed that resident food preferences should be followed and that it was the responsibility of dietary aides and licensed nurses to check food trays for accuracy. The facility's policy stated that residents would receive the correct diet with preferences accommodated as feasible, and that nursing personnel were responsible for ensuring residents were served the correct food tray. Despite these policies and procedures, the resident's food preferences were not honored, resulting in her not eating the provided meal.
Plan Of Correction
A. How corrective actions will be accomplished for those residents found to have been affected by the deficient practice 1. On 7/9/2025, Resident #1's dietary preference card and tray ticket were reviewed by the Director of Nursing (DON) and the Dietary Manager. 2. On 7/9/2025, the Assistant Director of Nursing (ADON) met with the resident to provide reassurance that the facility is honoring their documented food preferences. 3. A 1:1 in-service was provided to the Dietary Manager by the Registered Dietitian on 07/10/2025. B. How facility will identify other residents having the potential to be affected by the same deficient practice 1. All residents with food preferences have the potential to be affected by this deficient practice. 2. Beginning on 7/10/2025, a full audit of all residents' dietary preference meal tickets and meal trays was conducted by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) to ensure that all food dislikes and preferences were accurately reflected on each resident's meal tray. 3. No other deficiencies were identified. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: 1. On 7/10/2025, in-service training was provided to all dietary staff and dietary aides on reviewing tray tickets before each meal service and cross-checking meals with residents' documented food preferences and dislikes. 2. On 7/10/25, all licensed nursing staff and CNAs received in-service training focused on the importance of honoring resident food preferences, confirming the accuracy of meal tray contents, and ensuring alignment with documented food preferences before delivery to residents. 3. Resident food preferences will be added into each resident's care plan, and all food dislikes will be included in the resident's diet orders to ensure consistency and accuracy in meal preparation. 4. An audit tool was developed for the RN Supervisor / Licensed Designee to cross-check tray tickets and meal trays to ensure that meals are served according to each resident's documented food preferences. Audits will be conducted daily for three days, then weekly for two weeks, and monthly for three months. 5. Any inconsistencies found during audits comparing meal trays with documented food preferences will be promptly reported to the Director of Nursing (DON) and the Dietary Manager and will be addressed immediately upon identification. D. How the facility plans to monitor its performance to make sure that solutions are sustained: 1. The DON/Facility administrator and dietary manager will monitor corrective actions through ongoing compliance and audit results from comparisons of meal trays to documented food preferences completed by the RN supervisor/designee. 2. The DON/Administrator will report the findings and trends of meal trays to documented food preferences audits to the QAPI Committee monthly for review and recommendations. 3. The QAPI Committee will monitor the process for 3 months or until 100% compliance is achieved.