Failure to Address Repeated Grievances Regarding Diabetic Diet
Penalty
Summary
The facility failed to appropriately address and follow up on repeated grievances voiced by a resident regarding the adequacy of food provided for a diabetic diet. The resident, who was cognitively intact and had diagnoses including diabetes, hypertension, peripheral vascular disease, hyperlipidemia, and asthma, experienced a significant weight gain of 35.8% since admission. Despite having an order for a diabetic, regular textured diet, the resident's electronic medical record lacked any progress notes from dietary or nutritional services and did not document the resident's ongoing food concerns. The facility's grievance log for the past six months also did not include any mention of the resident's complaints about the food provided. Multiple staff interviews confirmed that the resident had repeatedly voiced concerns about not receiving appropriate diabetic diet options, such as sugar-free items, and often chose not to eat the food served. Staff members, including LPNs and the certified dietary manager, acknowledged awareness of the resident's complaints, but there was no evidence of formal documentation or follow-up by dietary or grievance personnel. The grievance officer confirmed that no formal grievances had been filed for the resident, despite the facility's policy requiring staff to guide residents in filing written complaints when concerns are voiced.