Failure to Honor Resident Dietary Preferences and Ordered Supplements
Penalty
Summary
The facility failed to provide a resident with food that accommodated documented preferences and ordered supplements. On 01/12/2026 at 1:02 PM, the resident was observed lying in bed with the head of the bed at a 20-degree angle and an over-bed table holding an uneaten turkey casserole, uneaten carrots, and one 120 milliliter cup of fluid, with no health shake and no soup present. At that time, the resident reported that every day the facility sent the wrong food, that the facility never served the food on the menu, that soup had been requested but not provided, and that the resident could not eat the food that was sent. At 1:10 PM, an RN stated that dietary usually sent health shakes on the cart with the milk and, after checking four dietary carts on different hallways, reported that the kitchen had not sent any health shakes to the floor. At 1:20 PM, the Dietary Manager reviewed the resident’s dietary sheet and stated that the facility did not have soup and that health shakes were on the carts with the milk. The resident’s dietary sheet dated 01/12/2026 documented ordered supplements and preferences including “HEALTH SHAKE – 1 each,” “SOUP – 1 serving,” and “NO CASSEROLES,” which did not match the meal and items actually provided to the resident at the time of observation. These observations, interviews, and record review show that the resident did not receive the ordered health shake and soup and was instead served a casserole contrary to the documented preference of no casseroles, demonstrating a failure to accommodate the resident’s food and drink preferences as specified in the dietary sheet.
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