Failure to Provide Evening Meal to Newly Admitted Resident
Penalty
Summary
The facility failed to provide an evening meal to a newly admitted resident whose diagnoses included fracture of the pelvis, respiratory failure, and protein-calorie malnutrition. The resident was admitted to the facility in the early evening with a physician’s order for a regular diet with mechanical soft foods. According to the resident’s family member, they arrived at approximately 5:55 P.M., and no staff offered or brought any food to the resident. The family member reported seeing only one nurse, who stated the kitchen was closed for the day, leading the family member to go to a local restaurant to obtain food for the resident. The resident later stated that they were hungry, did not get much to eat for supper, and that their daughter had to bring food because the facility did not provide a meal tray. The Dietary Manager reported that they are notified of expected admissions via memo and that on the day in question they had prepared three or four meal trays for anticipated admissions, including a tray intended for this resident. The Dietary Manager explained that they must wait for nursing to enter the resident’s information into the EMR before entering diet information into the dietary system, and that if a resident is admitted before 7:00 P.M., nursing is expected to inform dietary of the admission and ask the resident what they would like for the meal. On this occasion, dietary staff were not informed that the resident had arrived, so they left a tray in the kitchen window for nursing to take when the resident came in. The next morning, the tray was still in the kitchen window and had not been passed to the resident. The Dietary Manager stated this was not the first time such an occurrence had happened. The DON, Administrator, and Medical Director each indicated in interviews that they would expect new or late-returning residents to receive some type of nourishment, such as a meal tray or sandwich.
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