Failure to Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's documented food preferences over a period of several weeks. The resident, who was cognitively intact and independent with eating, had a physician order for a regular diet and had specifically requested grits for breakfast and no orange juice. Despite multiple dietary communication slips and verbal reminders from both the resident and nursing staff, the resident continued to receive orange juice and was not served grits as requested. Observations confirmed that the resident's breakfast trays repeatedly included orange juice and omitted grits, requiring the resident to ask staff each morning to correct her meal. Interviews with the resident, nursing staff, and the Dietary Manager revealed that the communication slips indicating the resident's preferences were overlooked and not entered into the electronic record. The Dietary Manager acknowledged that she had discontinued her previous system of initialing slips after updating preferences, which contributed to the oversight. The resident expressed frustration at having to repeatedly request her preferred breakfast items, and the issue persisted until it was finally addressed after several weeks of noncompliance.