Failure to Provide Timely Meals to Residents Receiving Room Trays
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were provided in a timely manner and in accordance with residents’ needs and preferences for two cognitively intact residents receiving room trays. For one resident with a BIMS score of 15/15, staff were overheard at the nurses’ station discussing that the resident had just awakened and did not have a breakfast tray. The resident later reported she did not get breakfast and that no one woke her up for breakfast, stating she frequently did not receive meals and that her son had purchased a mini fridge so she would always have food available. Surveyors observed the mini fridge in the room and a bag of doughnuts from her family on the overbed table, which the resident chose to eat instead of breakfast because it was close to lunchtime. Facility documentation for that morning’s breakfast was marked “NA” (not applicable) for the resident, indicating breakfast was not provided. For another resident with a BIMS score of 15/15, lunch trays were delivered to the unit, with trays identified either by orange sticky notes or meal tickets. After trays were distributed, staff used a walkie talkie to notify dietary that this resident did not have a tray on the cart, but no response was received. More than 30 minutes after initial tray delivery, the resident activated the call light and reported to a CNA that lunch had not yet been received. The CNA then delivered a room tray to the resident, which occurred after the facility’s stated lunch service window of 11:15 AM to 12:15 PM. The CDM reported that dietary is notified of needed trays via meal tickets or last-minute walkie calls and stated there had never been a problem with residents not being served, while the DON reported CNAs are responsible for taking trays to rooms and documenting intakes and that residents are expected to be offered three meals a day.
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