Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to ensure that a resident received food items in accordance with their documented preferences, resulting in dissatisfaction and the potential for nutritional decline and gastrointestinal upset. The resident in question had a history of vascular dementia, Barrett's esophagus with dysplasia, diabetes mellitus, and dysphagia, and was severely cognitively impaired. The care plan and Kardex indicated specific food preferences, including a dislike for spicy foods and mac n cheese, and a preference for seafood and tomato juice at meals. Despite these documented preferences, the resident continued to receive spicy foods, which the resident's Durable Power of Attorney (DPOA) reported caused heartburn and gastrointestinal discomfort. The DPOA had repeatedly informed staff of these preferences, but the issue persisted, and the resident was observed to reject spicy food items such as potato wedges. Interviews with dietary staff revealed a lack of awareness and communication regarding the resident's food preferences. The dietary aide responsible for meal preparation stated that she was only aware of the restriction on tomato juice and was not informed of other preferences or dislikes. The Registered Dietician (RD) confirmed that food preferences were recorded at admission and updated as needed, but relied on floor staff or the interdisciplinary team to communicate any changes. The RD was not aware of the DPOA's concerns and did not routinely reach out to family members unless there were significant nutritional issues, such as weight loss or ongoing gastrointestinal upset. The meal tickets for the resident did not reflect the documented dislikes or the need to avoid spicy foods. Facility policy required dietary staff to obtain food preferences, allergies, or intolerances within 72 hours of admission and to update this information as needed. However, the process for updating and communicating these preferences was not effectively implemented, resulting in the resident receiving meals that did not align with their documented needs and preferences. This failure was confirmed through observation, interviews, and record review.