Failure to Provide Palatable, Properly Prepared Food to a Resident With Nutritional Risks
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide palatable, properly prepared food to a resident with documented nutritional and hydration problems, a history of protein calorie malnutrition, multiple food allergies, and limited food choices. The resident’s care plan stated that the resident had multiple food complaints, would only eat requested items, and was to receive specific food items as requested. Physician orders included a regular diet with regular texture, thin liquids, and double portions of fish or chicken and eggs at breakfast. The resident’s MDS showed independence with eating but a need for setup or clean-up assistance. During kitchen observation, surveyors noted a container of strawberries on the counter with an open date several days earlier. In interviews, the resident reported receiving burnt hard-boiled eggs daily, burnt chicken and broccoli, and old, moldy strawberries, and stated that when trays were sent back, replacement meals were also overcooked. Surveyors directly observed the resident eating broccoli that was mushy and overcooked and strawberries that appeared acceptable on top but looked old when turned in the container. On another observation, the resident had a hard-boiled egg that was green in color, rubbery, and peeling in layers, and stated the food that morning was not good. The cook who prepared breakfast reported boiling the eggs for 15 minutes, then holding them in a warmer for over an hour before service, and acknowledged not following any instructions or recipes for cooking hard-boiled eggs. The cook agreed that the egg shown looked oxidized and firmer than expected and stated that residents would be disappointed, possibly angry, and would not like the food, with the potential to be undernourished with possible weight loss when food is overcooked. The dietary supervisor acknowledged that the broccoli and eggs served to the resident were overcooked. These findings conflicted with the facility’s policies requiring that each resident receive a nourishing, palatable, well-balanced diet, that food appear palatable and attractive, and that staff follow the facility’s hard-boiled egg preparation procedure.
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