Resident Received Incorrect Diet Due to Meal Tray Delivery Error
Penalty
No penalty information released
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
A resident was observed receiving the incorrect breakfast tray, which was intended for another resident with a different prescribed diet. The meal ticket on the tray indicated it belonged to a resident who was ordered a Dysphagia Level 2 diet, while the affected resident was ordered a regular diet by the physician. Staff interviews revealed that an agency GNA mistakenly delivered the wrong tray, and the error was subsequently identified and the tray removed. The incident was reported to the LPN and later brought to the attention of the DON. Medical record reviews confirmed the dietary orders for both residents involved at the time of the incident.