Failure to Provide Timely and Appropriate Meals to Residents
Penalty
Summary
The facility failed to provide scheduled meals and requested alternatives to two out of three sampled residents, resulting in missed or delayed meals. One resident, admitted with orthopedic aftercare, muscle weakness, and a stage 3 pressure ulcer, required set-up assistance for eating and had a regular diet order with a large portion of protein for breakfast. This resident did not receive a requested alternative sandwich after disliking the breakfast meal and ultimately received the sandwich much later than the scheduled mealtime. Another resident, admitted with multiple fractures and heart failure, was independent in eating and had a regular diet order with the option for double portions upon request. Record reviews and staff interviews confirmed that both residents did not consistently receive three meals per day as required, and that meals were not always provided within the facility's policy timeframe of 45 minutes from request or scheduled mealtime. The DON acknowledged that all residents should receive their scheduled meals, and documentation showed that the deficiency occurred over a period of time, affecting the residents' access to timely and appropriate nutrition.