Failure to Provide Meals and Beverages According to Resident Preferences
Penalty
Summary
Facility staff failed to provide meals and beverages in accordance with residents' documented preferences and meal tickets for multiple residents. One resident, who requested a grilled chicken salad and milk for lunch, did not receive the requested items on his tray, and reported that this was a recurring issue. The dietary aide confirmed that meal tickets are supposed to reflect residents' likes and dislikes, and that all items listed should be served. Facility documentation indicated that meal tickets are intended to identify allergies, preferences, and special requests, but these were not consistently followed. Several residents in the dining room did not receive milk as indicated on their meal tickets, with some only being served tea despite specific instructions for milk and other beverages. One resident, who could not drink tea and was supposed to receive milk, did not receive it until prompted by the surveyor. The dietary manager acknowledged the issue and considered changing the process to ensure accuracy. The registered dietician was unable to provide a completed preference form for one resident, and other residents also reported not receiving their preferred beverages as documented in their food preference interviews and meal tracker forms. Another resident, who preferred oatmeal for breakfast, was served cold cereal instead, despite the meal ticket specifying oatmeal. The certified nursing assistant and unit manager confirmed that the resident should have received oatmeal, and the kitchen had it available, but no explanation was given for the error. Facility policy requires that food and beverage preferences be identified, documented, and followed, but these procedures were not adhered to, resulting in residents not receiving their preferred or requested meals and beverages.