Failure to Provide Physician-Ordered Supplements and Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide meals that accommodated resident allergies, physician-ordered supplements, and stated preferences for multiple residents. For one resident with COPD, failure to thrive, and dementia on hospice, the physician ordered a regular diet with a four-ounce fortified nutritional treat at lunch. However, observation revealed that the fortified treat was not included on the lunch tray, and this omission was confirmed by both a CNA and review of the meal ticket. Another resident with systemic lupus and recent significant weight loss had a physician order for a regular diet with no bananas or seafood due to allergies and a daily fortified nutritional treat at lunch. Observation and interviews confirmed that the fortified treat was missing from the lunch tray, despite being indicated on the meal ticket. Additional deficiencies were observed regarding resident meal preferences. One resident with anorexia and moderate cognitive impairment was supposed to receive apple juice according to the meal ticket but was instead given cranberry juice and, on another occasion, lemonade. These errors were verified by both staff and the resident, who expressed dissatisfaction with the incorrect beverage. Another resident with chronic respiratory failure and muscle wasting selected specific breakfast items, including a hash brown patty and cranberry juice, but did not receive the hash brown and was given orange juice instead. Staff confirmed the kitchen had run out of hash browns. A further resident with COPD and moderate cognitive impairment also did not receive a selected hash brown patty for breakfast, as the kitchen had run out. Across these cases, the facility did not consistently provide food and beverages according to physician orders, resident allergies, and stated preferences, as evidenced by direct observation, record review, and staff interviews. These failures affected five of six residents reviewed for food and drink, out of a facility census of 69.