Failure to Follow Resident Dietary Preferences and Tray Assembly Tickets
Penalty
Summary
The facility failed to follow tray assembly tickets reflecting resident dietary preferences and physician orders for two residents. For one resident with diagnoses including anemia, hypertension, and diabetes, the tray assembly ticket specified a hamburger on a bun with ketchup, but the resident was served Salisbury steak with gravy instead. The nurse aide confirmed the discrepancy, stating the tray was given without checking the ticket, and acknowledged that the meal did not match the resident's listed preferences. Another resident with heart failure, hypertension, and depression had a physician order for a regular diet with no mayonnaise and no salt packet. Despite the tray assembly ticket specifying cornflake chicken breast and other items, the resident was served Salisbury steak with gravy and noodles. Additionally, the resident's tray included two salt packets, contrary to the dietary restriction. Both the nurse aide and the Dietary Director confirmed that the meals served did not align with the tray assembly tickets or the residents' dietary preferences and restrictions.