Failure to Serve Meals at Palatable Temperatures Due to Delayed Tray Delivery
Penalty
Summary
Facility staff failed to provide food at a palatable temperature for one resident during a lunch meal service. The resident, who was dependent on staff for feeding due to quadriplegia and other medical conditions, received their meal significantly later than when trays were delivered to the unit. Specifically, the resident's tray was delivered at 12:43 PM, over 30 minutes after the trays arrived on the unit at 12:10 PM. Test tray temperatures at the time of delivery were recorded as 118.6°F for fish, 122.8°F for noodles, and 120.0°F for zucchini and tomatoes, which were acknowledged by the dietary manager as not being warm enough. The dietary manager also reported frequent complaints about food temperatures and attributed the issue to delays in tray delivery by staff. The resident confirmed during an interview that the food was only warm at best and not good to eat at that temperature. The facility's policy requires prompt delivery of food to ensure it is served at safe, palatable, and high-quality temperatures, as preferred by residents and customary practice. The deficiency was identified through observation, resident and staff interviews, and review of clinical records, with no further information provided prior to the survey exit.