Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of two residents, as identified through observation, interview, and record review. One resident, who was readmitted with diagnoses including toxic encephalopathy, sepsis, and pneumonia, had a severely impaired cognitive status and required substantial assistance with eating. The resident's dietary profile indicated a preference for mashed potatoes at lunch and dinner, and this preference was noted on the meal ticket. However, during a lunch observation, the resident was not served mashed potatoes as indicated, and the Assistant Dietary Supervisor confirmed the omission. Another resident, admitted with encephalopathy, dysphagia, and Alzheimer's disease, also had severe cognitive impairment and required assistance with eating. This resident's dietary profile specified a preference for coffee with all meals, and the meal ticket for lunch included coffee. During observation, the resident's lunch tray did not include coffee, and both the resident and staff confirmed the omission during interviews. The Director of Nursing and Registered Dietician both acknowledged the importance of following meal tickets and resident preferences to ensure adequate nutritional intake. A review of the facility's policies indicated that the dietary department is responsible for providing meals consistent with residents' preferences as documented on tray cards and that therapeutic diets should align with the resident's goals and preferences. Despite these policies, the facility did not follow the documented preferences for the two residents, resulting in the identified deficiencies.