Failure to Support Resident Choice for Morning Coffee
Penalty
Summary
Facility staff failed to honor a resident's right to self-determination and choice by not providing coffee in the mornings prior to breakfast, despite the resident's clear preference and repeated requests. The resident, who had no cognitive impairment and required assistance with activities of daily living, expressed her desire for coffee before breakfast to both staff and surveyors. She reported that staff were aware of her preference, but she was consistently told she could not have coffee until breakfast trays were served. The resident stated that the only way to obtain coffee earlier was to purchase it herself from outside the facility. Observations confirmed the resident's routine of waiting near her room and in the hallway for the breakfast trays, asking staff about the timing of coffee delivery, and expressing her dissatisfaction with the inability to have coffee before breakfast. The clinical record review and interviews with staff, including the Dietary Manager, corroborated that the resident's request for early coffee was not accommodated. The deficiency was identified through direct observation, resident and staff interviews, and review of clinical documentation.