Failure to Follow Resident Meal Preferences and Dietary Instructions
Penalty
Summary
The facility failed to provide meals in accordance with resident preferences and dietary instructions for two residents. In one instance, a resident did not receive a chocolate ice cream dessert as listed on her meal ticket, despite her stated preference and the expectation that her meal would include this item. Observations and interviews with staff confirmed that the resident's preference was documented and should have been honored, but the item was omitted from her tray. The Certified Dietary Manager (CDM) and Director of Nursing (DON) both acknowledged that the resident should have received her preferred dessert and that staff are expected to check trays for accuracy before serving. In another case, a resident with moderate cognitive impairment was served a dessert despite a clear instruction on the meal ticket to not serve sweets or desserts. The resident's meal ticket, dietary records, and staff interviews confirmed that the dessert was not appropriate for this resident. The CDM and DON both stated that the resident's dietary preferences and restrictions should have been followed to ensure person-centered care and nutritional needs were met. Facility policies and job descriptions reviewed also indicated that staff are required to check meal tickets for allergies, preferences, and specific instructions before serving meals.