Failure to Serve Meal Trays Simultaneously Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a resident was not served her lunch tray at the same time as her tablemate in the dining room. Observations showed that while one resident at the table received her meal, the other resident had to wait, with staff passing trays to other tables before serving her. The resident expressed that she often had to wait for her meal and felt uncomfortable when her tray was delayed, especially when her tablemate had already finished eating by the time she received her food. The resident involved had multiple medical diagnoses, including heart failure, type 2 diabetes with complications, hypertension, stroke, convulsions, lack of coordination, anxiety, and depression. Her care plan included monitoring eating habits due to unplanned weight gain, but she was independent with eating. The delay in meal service was attributed to her not being included on the list of residents eating in the dining room, which resulted in her tray being placed with the hall trays instead of being served with her tablemate. Interviews with staff, including the dietary manager, CNA, DON, and ADM, revealed that the facility's practice was to serve all residents at the same table simultaneously. However, there was no formal written policy for meal tray service in the dining room. Staff acknowledged that failing to serve residents together could make them feel left out or upset and that it was the responsibility of nursing staff to ensure all residents at a table received their meals at the same time. The incident was linked to a lack of communication and monitoring regarding which residents were eating in the dining room.