Failure to Complete Timely Nutrition Assessments and Honor Dietary Preferences
Penalty
Summary
The facility failed to ensure that nutritional assessments were completed in a timely manner to determine dietary preferences and failed to honor food preferences for two residents. For one resident with multiple diagnoses including congestive heart failure, diabetes, and moderate cognitive impairment, the care plan and physician orders did not specify the resident's request to avoid pork and beef, despite documentation and interviews indicating these preferences. Observations confirmed that this resident received beef on his meal tray, and staff verified the presence of beef despite the resident's stated aversion. Another resident, with a history of kidney transplant, end stage renal disease, and diabetes, also reported a preference to avoid pork for religious reasons. Although the dietician was made aware of this preference, the resident continued to receive pork on meal trays and had to return them. Staff interviews revealed that dietary staff did not consistently review meal tickets thoroughly and relied on cheat sheets, which were incomplete regarding certain preferences. The facility's policy required interviews within 72 hours of admission to determine food preferences, but this was not completed for one of the residents involved.