Failure to Follow Posted Menus and Resident Food Preferences
Penalty
Summary
The facility failed to ensure that menus were followed and served as posted for two residents, resulting in meals that did not match the planned or posted menus and resident preferences. For one resident, multiple meal trays did not correspond with the posted or planned menus, with specific items such as cold cereal and Cream of Wheat missing from breakfast trays, and mixed vegetables substituted for listed menu items like Brussels sprouts and butternut squash at lunch. The resident reported that the facility did not inform them of menu changes, and observations confirmed discrepancies between the posted menus, planned menus, and what was actually served. Another resident, who was cognitively intact and had documented food dislikes, received meals that included items from their dislike list, such as white bread, despite these preferences being clearly noted on the meal tray ticket. This resident also did not receive all items listed on their meal ticket, such as yogurt, and their trays did not match the posted or planned menus on several occasions. Interviews with staff revealed a lack of clarity and breakdown in the process for updating and communicating resident food preferences, with the interim Dietary Manager stating that no new preference slips had been received and the front desk receptionist unaware of receiving any slips from nursing. The facility's policy required that menus be planned in advance, served as written unless substitutions were necessary, and posted in relevant areas. However, observations and interviews demonstrated that these procedures were not consistently followed, leading to residents receiving meals that did not align with their dietary orders, posted menus, or personal preferences. The deficiency was identified through direct observation, resident and staff interviews, and review of facility records and policies.