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F0558
D

Failure to Accommodate Resident Food Preferences Due to Unauthorized Removal of Dietary Items

Overland Park, Kansas Survey Completed on 05-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Nursing staff failed to accommodate a resident's food preferences by removing dietary items from her meal trays, despite physician orders and care plan directives. Specifically, staff took toast and breadsticks from the resident's trays on multiple occasions, citing concerns about her blood glucose levels. The resident, who had a history of diabetes, Alzheimer's disease, and multiple other medical conditions, was on a regular diet with double protein and diabetic condiments as ordered by her physician. The care plan instructed staff to provide the diet as ordered and monitor intake, but staff instead made independent decisions to remove food items without consulting the physician. Observations and interviews revealed that both CNAs and licensed nurses routinely removed bread or dessert from diabetic residents' trays based on blood sugar readings, rather than following the prescribed diet orders. The resident was observed attempting to retrieve bread that had been taken away and even took bread from another resident's tray. Facility policy and administrative staff confirmed that residents should receive the food served on their trays and that staff should not remove food items. This practice was inconsistent with the resident's rights and the facility's own policies.

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