Failure to Honor Resident Mealtime Preference Results in Cold, Unpalatable Food
Penalty
Summary
The facility failed to honor a resident's request for a later breakfast time, resulting in the resident consistently receiving cold and unpalatable food. The resident, who preferred to sleep late and wake around 9-9:30 a.m., repeatedly communicated her preference for breakfast to be delivered at that time. Despite this, staff continued to deliver breakfast trays early in the morning, leaving them at the bedside while the resident was still asleep. Observations confirmed that the food remained untouched and cold by the time the resident awoke. The resident's private caregiver and a CNA both confirmed that the issue had been raised with the facility multiple times, but no changes were made to accommodate the resident's preference. The resident's care plan documented a risk for altered nutrition and a goal to respect her right to choose and honor food preferences, yet there was no documentation of her preferred breakfast time in the care plan or nutritional notes. The Registered Dietician stated that resident mealtime requests should be honored within a reasonable window for food safety, and the facility's policy also indicated that resident mealtime preferences should be honored and food should be served at appropriate temperatures. Despite these policies and the resident's mental capacity to make decisions, the facility did not adjust its practices or documentation to meet the resident's request.