Failure to Provide Resident Food Preferences and Complete Meals
Penalty
Summary
A resident with diagnoses including osteomyelitis, anemia, and diabetes was admitted to the facility and had a documented food preference form specifying desired and undesired foods. The form indicated preferences for chocolate nutritional supplements, hot grits, and a daily breakfast of eggs, bacon, and biscuits with gravy, while also listing foods the resident did not want. The resident was cognitively intact and required moderate assistance with meals, but had no dental or swallowing deficits. The care plan noted a risk for nutritional deficit and the use of a nutritional supplement. On multiple occasions, the resident did not receive the food items listed on her meal ticket or in accordance with her stated preferences. During one observation, the resident reported not receiving eggs and bacon as ordered, instead receiving a small sausage, and stated this was a recurring issue. She also reported receiving meals without meat and not always receiving requested items such as gravy or an English muffin. The resident expressed concern about being hungry and having lost weight prior to admission. Staff interviews confirmed that missing food items and unmet preferences were known issues, with explanations including insufficient food being sent from the hospital kitchen and human error in entering preferences into the menu system. The dietary and nursing staff were aware that food items were sometimes missing from trays, and substitutes were provided when possible, but not always in accordance with resident preferences. The system for entering dietary preferences required daily manual input, and omissions could occur, resulting in residents not receiving their chosen foods. There was no consistent process for ensuring that missing items were replaced or that additional food was requested from the hospital kitchen when shortages occurred.