Menu Review and Nutritional Adequacy Deficiencies
Penalty
Summary
The facility failed to ensure that menus were reviewed and approved for nutritional adequacy in accordance with nationally accredited standards. During a kitchen tour, it was revealed that the facility followed a three-week cycle menu, but the menus provided were not signed or dated by a qualified nutrition professional to confirm their adequacy. Additionally, the facility's dietitian was unaware of who developed or reviewed the menus, indicating a lack of oversight and accountability in the menu planning process. The surveyors found discrepancies in the dietary care provided to three residents. For instance, one resident's care plan included a physician's order for a specific dietary supplement twice a day, but this was not reflected in the resident's dietary records or meal tickets. Similarly, another resident's preferences and physician's orders were not accurately documented or followed, leading to inconsistencies in the meals served. These issues were compounded by the dietitian's admission that there was no formal system to ensure that dietary recommendations and updates were implemented. Interviews with residents and staff further highlighted the deficiencies. Residents reported receiving meals that did not match their documented preferences, and the dietitian acknowledged the lack of a formal follow-up system to verify that dietary changes were executed. The facility's electronic medical record system was supposed to link with the food service software to automatically update dietary information, but manual errors and communication breakdowns persisted, resulting in unmet nutritional needs and preferences for the residents.
Plan Of Correction
Element 1 This deficiency was corrected by having the NJ Ex Order 26.4(b)(1) and NJ Ex Order 26.4 Menus reviewed and approved by a Licensed Dietitian. Additionally, a Food Preference audit was performed to ensure that all resident food preferences were included in the facilities meal ticket system, and that the residents received meals based on their food preferences. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Food Preference audit was performed on 1/27/2025 to ensure all residents' food preferences were included in the facilities meal ticket system, and that the residents received meals based on their food preferences. During the audits, seven residents expressed additional food preferences, which were immediately added to the meal ticket system. Additionally, the food preference audit will continue to ensure that the facility remains in compliance with F803. Element 4 To maintain and monitor ongoing compliance, a Food Preference audit is being conducted by the dietitian or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.