Failure to Adhere to No Added Salt Diet Orders for Multiple Residents
Penalty
Summary
The facility failed to ensure that therapeutic diets, specifically No Added Salt (NAS) diets, were properly implemented for four residents with various medical conditions, including Alzheimer's disease, hypertension, chronic kidney disease, diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease, acute congestive heart disease, and acute respiratory failure. During meal observations, each of these residents received lunch trays that included salt packets, despite their physician-ordered NAS diets. Tray cards for these residents clearly indicated the NAS diet order, yet the presence of salt packets on their trays was noted by both surveyors and the facility's registered dietitian. Interviews with staff, including a registered dietitian, confirmed that the dietary department was not following the tray cards and that salt should not have been provided to residents on NAS diets. The facility's diet manual also specifies that salt packets should not be sent on meal trays for residents prescribed a NAS diet. These findings were based on direct observation, staff interviews, and review of physician orders and diet manuals.