§483.60(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.
§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.
§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
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Observations:
Based on interview with resident and staff, and review of facility provided documentation, it was determined facility failure to ensure that one of 12 residents receive the breakfast meal. ( Resident R3)
Findings include:
Review of facility's policy 'Assistance with meals,' revised on March 2022, indicates that "nursing staff will remove food trays from the food cart and deliver the trays to each resident's room."
Interview with Resident R3, revealed that on January 7, 2025 his assigned nurse aide, employee E3, refused to change his bed linens upon request.
Further interview with Resident R3 revealed that on the following morning, January 8, 2025, he did not receive his breakfast tray - which he believes was part of retaliation from E3 after he reported her to unit manager, employee E4, for refusing to change his bed linens.
According to further interview with Resident R3, Employee E3 was his assigned nurse aide on January 8, 2025.
Interview with Unit manager, Employee E4, on January 24, 2025 at 1:00 pm, revealed that on the morning of January 8, 2025. Employee E3 was re-assigned and was not assigned to provide care for Resident R3. There was miscommunication among nurse aides which resulted in Resident R3 not receiving breakfast tray.
Review of facility provided grievance investigation revealed a statement from nurse aide, Employee E3, stating the following - " (January 8, 2025) Resident in 212b requested different aide for the day. At the time when I went to give 212a his breakfast 212b was sleeping and doesn't like to be woken up so we left his tray"
Further review of grievance report submitted due to 'resident did not receive breakfast', dated January 8, 2025, revealed that "meal was offered but resident said he was heading to lunch. Interviewed aides. Education provided regarding meal tray pass."
28 Pa Code 211.12(d)(1) Nursing services
| | Plan of Correction - To be completed: 02/18/2025
1.Facility cannot retroactively provide resident 3 with a missed meal.
2.Facility conducted full house audit on each meal to ensure every resident received a meal tray. Facility conducted full house audit to ensure all resident had meal tickets.
3.NHA/designee will re-educate all nursing department to ensure staff will remove food trays from the food art and deliver the trays to each resident room when eating meals on the unit.
4.NHA/designee will conduct random audits on one cart to ensure all residents receive a meal daily x4 weeks, weekly x4 and monthly x2. Facility will conduct audits to ensure all residents have a meal ticket 3x a week for 4 weeks, weekly x4 and monthly x2. Results will be submitted to QAPI for review and recommendations as needed.
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