Failure to Assess and Provide for Resident's Food Preferences During Nutritional Assessment
Penalty
Summary
A resident with chronic pulmonary edema and acute respiratory failure, who was cognitively intact and able to make decisions, was admitted to the facility. Upon review of the resident's records, it was found that neither the admission nor the comprehensive nutritional assessments included documentation of the resident's food preferences. The resident reported that no one had asked about their food preferences and expressed dissatisfaction with the food, specifically noting a desire for more meat, fresh vegetables, and less salty or overcooked food. Observations of meal trays confirmed that the food served was salty, mushy, and unappealing. Further review of the resident's records showed a significant weight loss of 7.54 lbs over approximately one month, with meal intake averaging only 25-50%. Interviews with the Director of Nursing and the Dietary Supervisor confirmed that the resident's food preferences were not assessed or incorporated into the care plan, and no measures were developed to address the resident's nutritional needs or prevent further weight loss. The facility's policy required that food preferences and dislikes be identified as part of the nutritional assessment, but this was not done for the resident.