Failure to Provide Palatable and Correctly Prepared Meal as Ordered
Penalty
Summary
The facility failed to ensure that a resident was served quality and palatable food, as required by facility policy and physician orders. During a lunch service, a resident with multiple diagnoses, including schizoaffective disorder, type 2 diabetes, and a consistent carbohydrate diet order, was served only one quesadilla with a hard tortilla instead of the two soft quesadillas indicated on the meal ticket. Additionally, the resident received a square of cake instead of the prescribed sugar cookie. The meal was found to be of poor quality, not attractive, and not in accordance with the resident's dietary needs and preferences. Observations and interviews revealed that the quesadilla was prepared ahead of time and left on the steam table for at least 30 minutes before being served, resulting in a hard texture. The dietary staff did not follow the meal ticket instructions, and the tray was not checked before being delivered to the resident. Both the Certified Nursing Assistant and the Dietary Services Supervisor confirmed that the resident did not receive the correct amount or type of food, and the food served was not palatable. The resident attempted to eat the quesadilla, found it too hard and bland, and subsequently refused to eat it, expressing dissatisfaction with the meal. Facility policy requires that food be prepared to conserve nutritive value, flavor, and appearance, and that meals be served as written on the menu and meal ticket. The staff interviews and record reviews confirmed that these procedures were not followed in this instance, resulting in the resident not receiving the appropriate meal as ordered and expected.