Failure to Accommodate Non-Verbal Resident's Dietary Preferences Due to System and Communication Issues
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with dementia, protein calorie malnutrition, moderate cognitive impairment, highly impaired hearing, and non-verbal status received meals that accommodated her preferences and needs. The resident communicated through writing, sign language, and a communication board, but staff did not attempt to communicate with her to offer menu options. On multiple occasions, the resident was served a peanut butter and jelly sandwich as her main entree, while other residents received meat-based entrees such as hamburger steak, chicken fried steak, or lasagna. Although alternate entrees like thyme chicken and egg salad sandwich were available and listed on the menu, these were not offered to the resident. The facility's dietary electronic system was programmed to track likes and dislikes, but due to a long list of beef dislikes for the resident, the system defaulted to providing a peanut butter and jelly sandwich as an alternative when beef was served. The system did not indicate that other available entrees should be offered, and the peanut butter and jelly sandwich, intended as a supplement, was incorrectly served as the main entree. The resident's responsible party confirmed ongoing issues with staff communication regarding food choices and clarified that the sandwich was meant to supplement, not replace, the main entree. Staff interviews confirmed the system's limitations and the lack of direct communication with the resident regarding her meal preferences.