Failure to Provide Palatable Food at Safe Temperature for Dialysis Patient
Penalty
Summary
Facility staff failed to provide a resident with food at an appetizing and safe temperature, as required by facility policy and federal guidelines. The resident, who had end stage renal failure and required dialysis three times a week, routinely had their lunch tray placed on the bedside table around noon, despite being away at dialysis until approximately 2:30 PM. Multiple observations confirmed that the lunch tray remained untouched on the bedside table for over two hours while the resident was absent. Upon returning, the resident reported that the food was cold and not reheated, and was unaware that a fresh tray could be requested. Staff interviews revealed that the tray was left in the room until the resident returned, and reheating was only done if specifically requested by the resident. The Dietary Director was not informed when the resident returned from dialysis and was unaware that the tray had been left out for an extended period. He stated that food should be discarded after two hours without refrigeration and that he expected to be notified to provide a fresh tray. The Director of Nursing and the Administrator both stated they were not aware of the practice of leaving trays out for extended periods and expected food to be served at proper temperatures. The facility's failure to coordinate meal service with the resident's dialysis schedule resulted in the resident being provided with cold, unappetizing food that had been left out for several hours.