Failure to Follow Planned Menus and Honor Resident Meal Preferences
Penalty
Summary
The facility failed to follow planned menus and honor resident preferences for multiple residents during observed meals. The written menu for one lunch specified baked ham, sweet potatoes, Italian green beans, and gelatin with whipped topping. Instead, one resident with diagnoses including moderate protein calorie malnutrition, epigastric pain, and gastro-esophageal reflux disease was served a grilled cheese sandwich, sweet potatoes, green beans, and a sealed gelatin cup without whipped topping. This resident, who had no cognitive impairment per a recent MDS assessment, stated she did not receive what was on the menu or what she preferred, and her responsible party confirmed her statement. On another date, the planned lunch menu called for bow tie pasta with Italian sausage, tomatoes and cream, tossed salad with dressing, diced peaches, juice of choice, and coffee or hot tea. Review of meal tickets for three residents showed that their meals should have included bow tie pasta with Italian sausage, tomatoes and cream, but they were served pasta with sausage and cream without tomatoes. One of these residents had diagnoses including type 2 DM, chronic kidney disease, peripheral arterial disease, anxiety, and depression, and a social service assessment documented moderate cognitive impairment. This resident stated he would have preferred the pasta with sausage, tomatoes, and cream as planned. The Administrator confirmed that the facility menus were not followed for the lunches in question.
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