Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's documented food preferences. Specifically, a female resident with multiple medical conditions, including chronic heart failure, stroke history, neurocognitive disorder, and other chronic illnesses, was served white rice for lunch despite her meal ticket clearly listing a dislike for all types of rice. Observation showed that she ate less than half of her meal, and she reported not eating much because she did not like rice. The meal ticket on her tray indicated her dislike for rice, but no substitute item was provided. Interviews with staff revealed that dietary, nursing, and CNA staff were responsible for checking meal tickets and trays to ensure accuracy with resident preferences, allergies, and dietary needs. Despite these procedures, the error was not caught, and the resident received a meal inconsistent with her preferences. Staff acknowledged the oversight and explained that the kitchen was responsible for matching trays to tickets, and that the resident should have received mashed potatoes as a substitute. The facility's policy required staff to inspect trays for accuracy and report discrepancies, but this process failed in this instance.