Failure to Honor Resident Diet Orders and Food Preferences During Regular and Emergency Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to honor resident food preferences and diet specifications, including during a period when the main kitchen was under renovation and an emergency menu was in use. One resident with Parkinson’s disease, COPD, heart disease, adult failure to thrive, anxiety, and a moderate cognitive deficit had physician orders and a care plan for a no concentrated sweets (NCS) diet with mechanical soft/regular texture, thin liquids, super cereal at breakfast, fortified foods three times daily, and health shakes three times daily. Despite this, the resident was observed at breakfast with a tray containing Fruit Loops, orange juice, milk, a mighty shake, coffee, cookies, pears, and a bowl of milk. The resident’s meal card documented a preference for Cheerios, and the Dietary Manager acknowledged that residents with diabetes should receive non‑sugar cereals such as Cheerios or Rice Krispies and that this resident should have been served the preferred cereal. Another resident with a diagnosis of diabetes reported being served peanut butter and jelly sandwiches for the past few days because the kitchen was down, and he was getting tired of them. Surveyors observed the kitchen under renovation, with appliances, cabinets, flooring, and sinks removed, and staff serving meals from tables in the dining room. The facility was using an emergency menu consisting largely of shelf‑stable foods. The written emergency menu for multiple days specified repetitive items such as juice, dry cereal, canned fruit, peanut butter cookies, pudding, reconstituted milk, and peanut butter and jelly sandwiches, indicating limited variety and repeated use of the same items over several days. Resident council documentation showed that residents had been informed of the upcoming kitchen renovation and menu changes, and that some residents expressed they did not want corned beef. The emergency menu nonetheless included corned beef on specified days, and on one such day kitchen staff served corned beef hash, green beans, cookies, and beverages. One resident refused the corned beef hash, telling staff to take it away and was then offered a corn dog or sandwich. Another resident, alert to person, place, and time, stated lunch was awful and reported eating a ham sandwich instead of the corned beef hash. A third resident, also alert, was observed making a deli sandwich from personal food and described lunch as awful and terrible. The Social Services Director confirmed that several residents at resident council had said they did not want corned beef, and the Dietary Manager acknowledged awareness that a few residents did not want corned beef hash but stated they did not ask all residents about their preference, despite a facility policy stating that individual food preferences would be assessed on admission and communicated to the interdisciplinary team.
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