Failure to Follow Planned Menu Due to Food Shortage
Penalty
Summary
The facility failed to adhere to its planned menu, which is a requirement under §483.60(c) for meeting the nutritional needs of residents. The facility's policy, dated 1/18/24, mandates that menus be planned in advance and served as written unless a substitution is necessary due to preference, unavailability, or special meal requirements. On 12/30/24, the facility's menu indicated that residents were to receive a lunch meal consisting of smothered chicken thigh, whole kernel corn, oven browned potatoes, cornbread, sliced pears, and coffee or hot tea. However, during the meal service on the 400-unit, five residents were observed receiving mashed potatoes instead of the planned oven browned potatoes. The Dietary Manager explained that the substitution occurred because they ran out of oven browned potatoes and confirmed that the residents were not informed of this change. The Nursing Home Administrator was unsure why the dietary department ran out of food, suggesting it might be due to not accounting for new admissions and an increased census in recent weeks.
Plan Of Correction
1. There were no actual resident complaints when the substitution was made to the menu. Dietary staff were educated on Menus and Menu policy, meeting resident needs, resident notification when a change is made to the menu, preparation in advance, and followed by the regional dietary manager on January 14, 2025, which included notification of Menu Changes and Substitutions timely. 2. The Dietary Manager will monitor meal preparations to ensure that enough food is prepared for all meals. 3. Administrator/designee will audit random meals 5 times a week for 4 weeks, weekly for 4 weeks, then monthly ongoing to ensure menus are followed, that substitutions are posted timely, and that enough food was made to ensure dietary staff are following the menu. 4. The Administrator will submit Food Substitution Audits to the Quality Assurance Performance Improvement Committee (QAPI) for review and recommendations at the monthly meeting.