Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the documented food preferences of a resident with a history of protein-calorie malnutrition and dysphagia. Despite clear documentation on the resident's meal slip and care plan indicating specific food dislikes—including eggs, white bread, toast, and broccoli—these items were repeatedly served to the resident. The resident reported that these foods were provided multiple times per week, and that staff did not offer substitutions or ask for meal preferences prior to serving. Observations confirmed that the resident was served scrambled eggs and white bread toast for breakfast, and broccoli for lunch, all of which were listed as dislikes on the meal slip. The resident expressed distress about receiving these foods, stating that eggs caused stomach upset and diarrhea, and that staff were aware of these preferences. The meal slips on the trays clearly indicated the resident's dislikes, yet the items continued to be served. Interviews with staff, including CNAs, the unit manager, dietary staff, the dietitian, and the DON, all confirmed that food preferences should be honored and that the process requires checking meal slips before serving trays. Staff acknowledged that disliked foods are sometimes missed and served, and that the expectation is to notify the kitchen if this occurs. The dietitian was unaware of the resident's specific reaction to eggs but confirmed that eggs should not have been served due to the documented dislike. There were no food shortages that would have necessitated serving the disliked items.