Failure to Serve Meals According to Scheduled Mealtimes
Penalty
Summary
The facility failed to serve meals in accordance with its own policy and scheduled mealtimes, resulting in two residents not receiving breakfast within the expected timeframe. According to the facility's posted schedule, breakfast is to be served at 8:30 A.M., and residents should receive their meals within one hour of the start time. However, observations and interviews revealed that one resident, who had multiple medical conditions including acute osteomyelitis, stroke, malnutrition, diabetes, and dementia, did not receive breakfast for two consecutive days after admission. On the second day, the resident expressed feeling hungry and neglected, and staff only became aware of the missed meal after being prompted, eventually delivering breakfast two hours late. Another resident, with diagnoses including a fractured femur, cognitive communication deficit, osteoporosis, GERD, and anxiety disorder, also received breakfast over 1.5 hours late on two consecutive days. This resident's care plan required small, frequent meals due to GERD and anxiety-related nutrition risk. The resident reported increased anxiety and a preference for breakfast at the scheduled time, as late meals caused discomfort and uncertainty. Staff interviews indicated a lack of clarity regarding why these delays occurred, despite established procedures for meal delivery and new admissions.