| 12687 |
GOLDEN LIVINGCENTER - BROKEN BOW |
285120 |
224 EAST SOUTH E STREET |
BROKEN BOW |
NE |
68822 |
2011-01-04 |
364 |
E |
|
|
45IC11 |
REFERENCE NUMBER: 175 NAC 12-006.11D Based on record review, meal observations, and interviews with residents and family members, the facility failed to serve food that were palatable to residents. This had the potential to affect the meal enjoyment and food intake for 7 residents (Residents 46, 59, 02, 45, 48, 26, and 05) that had expressed food palatability concerns and for 6 residents (Residents 31, 32, 34, 35, 38, and 41) that received a pureed diet on the Special Care Unit. The facility census was 61 and the survey sample size was 13. Findings are: A. Review of Resident Council meeting minutes revealed: - 12/17/10 "Pizza - too dry" and "Kitchen is out of everything ... example diet jelly, ranch dressing". 6 residents attended the meeting; Residents 46, 59, 02, 45, 48, and 26. B. Review of the GRIEVANCE TRACKING LOG revealed: - 12/17/10 from Resident Council: "Kitchen is out of everything. Example: diet jelly, ranch dressing. Do not always get what is asked for"; - 10/6/10 from Resident 46: "Food does not taste good"; C. Observation on 1/3/10 from 12:10 PM - 12:30 PM revealed individual packets of salad dressing were served with lettuce salad. Observations revealed French dressing served at the start of meal service, then was substituted for Italian dressing when the kitchen ran out of French dressing. At 12:15 PM, Dietary Aide (DA) - D poured Ranch dressing into 3 small bowls. The Ranch dressing was not served. Observations of nursing staff, serving the plated lunch to residents, revealed residents were not asked their preference of salad dressings. D. During an interview 1/3/11 at 1:45 PM, Resident 05 revealed (gender) did not eat the lettuce salad because the resident only liked Dorothy Lynch salad dressing and "they gave me Italian". Resident 05 stated that the facility had a French dressing that tasted close to Dorothy Lynch, "I would eat that", but wasn't given a choice of salad dressing. E. During an interview on 1/4/11 at 10:50 AM, Resident 45 revealed the pork chops were always tough, sometimes "you can't eat them". F. An interview with the Dietary Manager (DM) on 1/4/11 at 11:00 AM, revealed the DM was aware that residents had some food complaints, such as tough meat and had been trying to cook them using different methods to try and keep them tender. G. Observation on 1/3/11 at 11:53 AM revealed Cook-S placed individual bowls of jello on trays for Residents 31, 32, 34, 35, 38, and 41. The trays were placed in the hot cart and taken to the Special Care Unit (SCU) to be served for lunch. H. During an interview on 1/4/11 at 11:00 AM, the DM revealed the hot cart used to transport meals to the SCU did not have a cold temperature compartment. The DM stated the jello should have been placed on top of the cart to be taken to the SCU for lunch, because it would melt if placed inside the cart. I. Observation of the meal served on the Special Care Unit at 12:15 PM on 1/3/2011 found the jello that was served was liquid. The jello was served on the dinner plate that had been sitting in the hot cart to 7 Residents (Residents 35, 32, 41, 34, 31, 38, and 44). J. Interview with NA-E (Nurse Aide) on 1/3/2011 at 12:15 PM stated, " the jello was drinkable". K. Interview with a family member on 1/3/2011 at 12:16 PM stated, "the jello was soft so I poured it in a glass to drink". L. During an interview on 1/4/11 at 8:45 AM with Resident 46, the resident reported the facility food was " terrible " . Resident 46 specifically cited pork chops that were over-cooked and too difficult to chew, sandwiches served with no spread on the bread making them dry and difficult to swallow and dressing too dry to eat. Resident 46 stated that facility staff were aware of all the food concerns. Resident 46 reported attending resident council meetings and discussing food concerns at those meetings as well. Resident 46 reported that the facility knew about food palatability concerns but failed to fix the problems. Review of the GRIEVANCE TRACKING LOG confirmed that Resident 46 made a grievance that the " Food does not taste good " on 10/6/10. The documented resolution was that the Dietary Manager would meet with the resident once a week to see how the facility could improve the taste of the meals. Interview with Resident 46 on 1/4/11 confirmed that the Dietary Manager had been meeting with the resident weekly but stopped meeting approximately 2 months ago. Resident 46 felt like things got better when the meetings were taking place but confirmed that the problems were not fixed. Interview with the Dietary Manager on 1/3/11 at 2:15 PM revealed that Resident 46 had voiced food palatability concerns to facility staff. The Dietary Manager confirmed that the original plan was to meet every Friday with Resident 46 to address the concerns. The Manager reported not being able to meet with Resident 46 the past couple of weeks due to the Holidays. The Dietary Manager confirmed that there was no documentation of the weekly meetings to verify what food concerns were discussed and what plan was made to correct Resident 46 ' s concerns. M. A confidential interview on 1/4/11 with an interested family member revealed that the family member ' s loved one in the facility had voiced complaints about the food. The family member cited specific concerns such as the pork chops being over-cooked, hamburger patties being over-cooked and residents being served the same things over and over again. The family member felt like the facility was aware of the food problems but made little or no effort to fix them. |
2014-04-01 |