Failure to Honor Resident's No Fish Dietary Preference
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus, depression, and epilepsy was admitted to the facility with a physician order specifying a controlled carbohydrate, no added salt, regular texture, and no fish diet. Despite this order, the resident's food preference for no fish was not documented on the Diet Communication Form, and the dietary department was not informed. On the day following admission, the facility's menu included fish for lunch, and the resident was served a meal containing fish. The meal ticket on the resident's tray did not indicate the no fish preference, and staff members, including a CNA and an LVN, were unaware of the resident's dietary restriction at the time the meal was served. The deficiency was further evidenced by interviews and record reviews showing that the resident's food preference was communicated by a family member to nursing staff on the night of admission, but this information was not relayed to the dietary department or reflected in the resident's dietary documentation. The dietary supervisor only updated the Diet Communication Form after being informed of the issue by the family member. The facility's policy required that dietary profiles include diet orders and food dislikes, but this was not followed, resulting in the resident being served a meal that did not accommodate their documented preference.