Failure to Follow Resident-Specific Menu and Meal Preferences
Penalty
Summary
The facility failed to ensure that the menu was followed for a resident with multiple medical conditions, including Type 2 Diabetes, leukemia, and protein calorie malnutrition. On the specified date, the resident's lunch meal ticket indicated he was to receive two cheese manicotti with marinara, sautéed zucchini, garlic bread, smooth yogurt, and fruit as a dessert substitute per his request. However, observation revealed that the resident received only one manicotti without marinara sauce, zucchini, garlic bread, and vanilla pudding with a chocolate cookie instead of the requested fruit and yogurt. The resident reported that the food was unappealing, dry, and overcooked, and that the kitchen often forgot to include his fruit and yogurt. The lunch tray appeared untouched, and the resident stated he had snacks in his room instead. Interviews with the Dietary Manager (DM) and Registered Nurse (RRN) confirmed that meal tickets are expected to be followed as they reflect each resident's dietary needs and preferences. The DM acknowledged responsibility for monitoring kitchen staff and stated that the failure was due to staff being nervous and not thorough. The RRN indicated that the DM and Administrator are responsible for ensuring residents receive appropriate meals and attributed the failure to a lack of education or need for staff reeducation. Facility policy review confirmed residents' rights to a dignified existence and self-determination.