Failure to Provide Beverages According to Resident Preferences and Meal Tickets
Penalty
Summary
Facility staff failed to provide beverages, specifically milk, in accordance with residents' meal tickets and preferences during meal service on two units. Observations revealed that multiple residents were not served milk as indicated on their meal tickets, despite milk being available in the dining room. Residents expressed their preferences and needs for milk, with some requesting it directly from staff and not receiving it. One resident required Lactaid milk, which was not available, and another resident stated a need for milk due to dietary restrictions and was not provided with any beverage options other than tea, which she could not consume. Staff interviews confirmed that meal tickets were intended to guide beverage service according to each resident's preferences and needs, including allergies and special requests. However, staff did not consistently follow these instructions, resulting in residents not receiving the beverages listed on their meal tickets. The dietary aide acknowledged that it was the responsibility of aides in the dining room to serve beverages as indicated, but this was not done. The dietary manager was made aware of the issue during the meal service and indicated a desire to change the process to ensure accuracy, but residents continued to go without the appropriate beverages during the observed meals. Facility documentation and policy stated that meal tickets should identify and accommodate residents' beverage preferences and that the registered dietitian or nutritionist would adjust meal plans as needed. Despite these policies, several residents did not receive the fluids specified on their meal tickets, including milk, coffee, or juice, and in some cases, only received tea or a single beverage option. These failures were observed and reported to facility leadership, with no additional information provided prior to the exit conference.