Failure to Communicate Menu Substitution
Penalty
Summary
The facility failed to adhere to its planned menu, as evidenced by the substitution of a hamburger bun for a croissant during the dinner meal on February 4, 2025. The facility's policy, dated January 15, 2024, required that any food menu substitutions due to unplanned situations be communicated to residents prior to meal service. However, this communication did not occur. Observations during the dinner meal confirmed the substitution, and an interview with Dietary Aide 2 acknowledged the mistake, indicating that the Dietary Manager was responsible for updating staff and residents about such changes. Further interviews revealed that the residents were not informed of the menu change. The Resident Council President confirmed that he was not notified of the substitution. The Nursing Home Administrator also confirmed the substitution and acknowledged that residents were not informed prior to the meal. This lack of communication and failure to follow the established menu policy led to the deficiency noted in the report.
Plan Of Correction
1. No individual resident was named or harmed. 2. No residents were harmed by substituting a nutritionally equivalent bread type for lunch. Any resident has potential to be harmed by menu substitution. 3. Re-education of the individual cook and other cooks regarding the menu substitution policy and procedure has been given by the kitchen operator. 4. Random tray audits will be conducted weekly x 4 and then monthly x 2 to ensure that meal is served as posted. These audits will be reported to the Quality Assurance team for review. Dietary manager to monitor.