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F0692
E

Failure to Provide Physician-Ordered Therapeutic Diets

Montclair, California Survey Completed on 04-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide physician-ordered therapeutic diets to three residents as observed during dining and record review. Two residents with orders for a cardiac diet, which includes low fat and low sodium requirements, were instead provided with a No Added Salt (NAS) diet because the Dietary Services Supervisor stated the facility does not offer a cardiac diet. The Registered Dietitian acknowledged that the residents' diet orders were not updated to reflect what the facility could provide, and the dietary staff did not ensure the electronic health record matched the actual diet being served. Facility policy required the use of approved, standardized recipes to meet resident needs, but this was not followed for these residents. Another resident with diagnoses of type 2 diabetes and hypertension had a physician order for a fortified regular diet with NAS and consistent carbohydrate (CCHO) requirements. However, during lunch observation, the resident's tray card did not indicate the fortified component as ordered by the physician. The Treatment Nurse confirmed the tray card did not match the physician's order, and the Registered Dietitian stated the correct diet should have been followed. Review of the facility's tray card policy showed that dietary staff were required to update tray cards upon receipt of new or changed diet orders, but this procedure was not followed.

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