Failure to Honor Documented Food Preferences for a Dialysis Resident
Penalty
Summary
The facility failed to provide meals that accommodated a resident’s documented food preferences. The resident, who had end stage renal disease, dependence on renal dialysis, and heart failure, was cognitively able to express needs and understand others, and required only supervision or partial assistance with activities of daily living. The resident’s care plan, dated 3/15/2026, documented a goal that the resident would receive meals aligned with food preferences daily and would verbalize satisfaction most weeks. Interventions directed staff to review the resident’s food preference sheet upon admission, update it as needed, and ensure alternative meal choices were provided if the main entrée conflicted with the resident’s preferences. On review of the resident’s diet orders, the resident was to receive a renal 80 g protein, constant carbohydrate diet with regular texture. The resident’s lunch ticket for 03/16/2026 listed specific dislikes, including pasta. During a concurrent dining observation, record review, and interview on 03/16/2026, the resident’s lunch plate was observed to contain penne pasta despite the documented dislike. The Dietary Manager confirmed that the resident disliked pasta and might not eat the food served, and stated that LVNs were responsible for comparing lunch tickets with lunch trays to ensure residents received the correct diet and preferences. The facility’s policy on Resident Food Preferences required that preferences be assessed upon admission, communicated to the IDT, and documented in the care plan, but the observed meal did not reflect the resident’s documented preference to avoid pasta.
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