Failure to Honor Resident Choice Regarding Dietary Orders
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices about significant aspects of their life, specifically the right to refuse dietician orders. The resident was admitted with diagnoses including traumatic subdural hemorrhage, anemia, urinary retention, and repeated falls. A quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Dietician orders dated 01/09/26 specified a regular diet with soft and bite-sized texture and thin liquid consistency. During a dining room observation on 01/28/26 at 12:52 pm, the resident requested a tortilla and was told he could not have one due to his diet order, after which he pushed his plate away and did not eat his meal. Later that afternoon, during an interview, the resident stated he really wanted to eat a tortilla, reported he had been told he could not have one because he might choke, and stated he understood the risks and still wanted a tortilla. In a subsequent interview on 01/30/26 at 4:26 pm, the DON confirmed the resident was on a soft, bite-sized diet and acknowledged that the resident had the right to refuse his dietary orders. The DON stated that staff should have communicated with the nurse or dietician to provide the resident the opportunity to refuse his dietary orders so he could have a tortilla, confirming that this process did not occur at the time of the incident.
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