Individual Meal Observation

Individual Meal Observation Audit

Resident ______Date ______

Location of observation Dining room Resident room Restorative program Other ______

Meal Observed Breakfast Lunch Dinner (circle one)

Menu for this meal ______

Diet order (from chart) ______

Diet as identified on meal card or as observed ______

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Functional Factors [F-311]

Resident is positioned properly at table YES____ NO ____

Adaptive equipment is available as care planned YES____ NO____ N/A ____

Eyeglasses, dentures and hearing aides in place YES____ NO____ N/A ____

Adequate assistance provided YES____ NO____ N/A ____

Resident is provided adequate time to eat YES____ NO____

Resident Choice and Preference [F-163 / F-246]

Does meal served correspond with known preferences and dislikes? YES___ NO____

Is resident able to understand therapeutic diet order? YES____ NO____

If YES, does resident agree with diet as ordered? YES____ NO____

Are condiments that resident desires provided with meal? YES____ NO____

Fluids of choice provided with meal YES____ NO____

Meal Appearance [F-325]

Attractively plated YES ___ NO____

Presents with variety YES ___ NO____

Dishware & silverware in good condition, disposables are not used YES____ NO_____

Resident Acceptance [F-325 / F-514 / F-163 / F-246]

Substitutions were offered if requested or food not eaten YES____ NO____

Substitutions obtained within 15 minutes of request YES____ NO____

Interviewable resident expresses satisfaction with meal & temp served YES____ NO____ N/A ____

Percentage of food intake observed ___0-25% ____25-50% ____50-75% ____75-100%

Percentage of food intake documented ___0-25% ____25-50% ____50-75% ____75-100%

Social / Dignity Factors [F-241]

Resident served at the same time as others at table YES____ NO____

Treatments and medications are not administered during the meal YES____ NO ____

If music or TV provided, it reflects resident interests YES ____ NO ____

If resident desires clothing protection, applied at time of meal serving YES ____ NO ____

Clothing protector used per resident choice YES ____ NO ____

Infection Control [F-441 / F-444]

Meal is maintained covered / protected until served to resident YES____ NO ____

`Handwashing and glove protocols observed by staff YES____ NO_____

COMMENTS (detail any “NO” responses):

“Confidential – Privileged Under Virginia Code §8.01-581.16 and 17 – For Quality Assurance Use Only”