Failure to Honor Resident's Plant-Based Dietary Preferences
Penalty
Summary
Facility staff failed to make reasonable efforts to honor and meet the meal choices and preferences of a resident who was admitted under hospice care with diagnoses including malignant ovarian and endometrial cancer, use of a nephrostomy tube, and bilateral lymphedema. The resident was cognitively intact and dependent on staff for most self-care activities, requiring setup assistance with eating. Despite a care plan identifying her risk for malnutrition and the need to identify food and beverage preferences, the resident reported ongoing nausea and vomiting over several days due to not receiving her preferred plant-based diet, which consisted mainly of beans, fresh vegetables, and fruit. The facility did not provide these preferred foods as previously agreed upon, and the resident's attempts to supplement her diet with outside food were hindered when staff discarded her purchased bean burritos due to storage policies. Additionally, the resident was informed she could not have a personal refrigerator in her room, further limiting her ability to store preferred foods. Interviews with facility leadership confirmed that the resident's person-centered care plan did not reflect her plant-based food preferences, and the dietary department had not consistently accommodated her nutritional needs as outlined in her care plan. The failure to update and follow the care plan and dietary preferences contributed to the resident's ongoing nutritional issues.