Failure to Follow Resident Food Preferences and Planned Menu
Penalty
Summary
The facility failed to honor a resident's documented food preferences and did not ensure that meals served were consistent with the planned four-week menu. Specifically, a resident with multiple diagnoses, including chronic non-pressure ulcers, diabetes mellitus, malnutrition, morbid obesity, and cognitive communication deficit, had a care plan and meal ticket specifying preferred foods for each meal. Despite these clear instructions, the resident reported receiving incorrect food items for breakfast, such as sausage links and one piece of bread with butter, instead of the specified two pieces of white toast, scrambled eggs with cheese, and cereal. The resident had previously communicated these concerns to the Assistant Director of Nursing and provided photographic evidence of the incorrect meal. Further review and observation revealed that the kitchen staff did not follow the planned menu for other residents as well. On one occasion, residents were served scrambled eggs or hard-cooked eggs, raisin toast, oatmeal, orange, grape juice, and milk, instead of the planned egg sandwich, cereal of choice, banana, and other items. The Kitchen Manager confirmed that substitutions were made due to missing food deliveries but could not explain why available menu items were not served as planned. These failures affected at least one resident and had the potential to impact all residents in the facility.