Failure to Provide Required Meal or Snack to Dependent Resident
Penalty
Summary
Staff failed to provide a morning meal or snack to a resident who was dependent on staff for eating assistance and had significant cognitive impairment, as well as a history of malnutrition and weight loss. The resident was observed in the dining room after breakfast time with only a cup of juice, and staff confirmed that the breakfast tray had already been discarded and no replacement was provided. The dietary manager and cook both stated they were not informed that the resident needed a meal or snack, despite facility policy requiring food and substantial snacks to be available 24 hours a day and for residents to be offered meals or snacks if they missed a scheduled meal. The resident's care plan specified a puree diet with nectar-thick liquids and documented the presence of severe pressure injuries. The facility's policies outlined open dining and the availability of food at all times, but these were not followed in this instance. Staff interviews revealed a lack of communication and follow-through to ensure the resident received appropriate nutrition after missing the scheduled breakfast.