Failure to Honor Resident's Documented Dietary Preference
Penalty
Summary
The facility failed to honor a resident's stated dietary preference for a peanut butter and jelly sandwich with every dinner meal, despite this preference being documented on the resident's dietary slip. The resident, who was moderately cognitively impaired but able to communicate and understand, reported that he or she could not tolerate regular dinner meals due to stomach upset and had repeatedly requested the sandwich as a substitute. The resident stated that the sandwich was only provided once or twice a week, and when it was not included on the dinner tray, the resident would not eat dinner. The resident also expressed reluctance to repeatedly ask staff for the sandwich, as the request had already been made and documented. Interviews with facility staff, including the dietitian and Food Service Director, confirmed that the resident's preference was known and should have been honored according to facility policy. The dietitian acknowledged the importance of providing the requested sandwich to prevent nutritional complications and confirmed that the information had been communicated to the dietary team. Despite this, the dietary staff did not consistently provide the sandwich as requested, resulting in the resident missing dinner meals when the preference was not met.