Failure to Post and Follow Accurate Menus for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that posted menus were accurate, prepared in advance, and followed for residents, specifically affecting three residents with severe cognitive impairment and self-care deficits related to Alzheimer's disease or dementia. Observations revealed that the posted lunch menu listed breaded pork chop, au gratin potatoes, zucchini and tomatoes, cornbread, and frosted poke cake, but residents were instead served ham, cauliflower, and Jello with fruit. No alternate menu options were posted, and the menu board did not reflect what was actually served. Interviews with staff and a family member indicated that residents did not receive menus, were not asked about their meal preferences, and that staff were unclear about who was responsible for communicating with families regarding food choices. The Dietary Manager acknowledged that the wrong menu was posted and that the dietary department was responsible for updating menus daily, including posting alternates. The Activities Director stated that she did not ask residents in the memory care unit about their meal preferences, and believed kitchen staff were responsible for this task. These actions and inactions resulted in the facility not meeting its own policies for menu planning and resident participation.