Failure to Provide Appropriate RCS Diet Desserts
Penalty
Summary
On 04/08/25, the facility failed to provide the appropriate dessert to all residents identified as being on a Reduced Concentrated Sweets (RCS) diet during lunch. According to the facility's menu for that day, residents on an RCS diet were to receive four ounces of fresh fruit in place of a brownie. However, observations of the tray line revealed that all residents, regardless of their dietary orders, received either a brownie or a pureed brownie as dessert. There was no evidence of fresh fruit being provided to any resident on the RCS diet. Record reviews for eleven residents with orders for an RCS diet showed that each had physician orders, care plans, and Minimum Data Set (MDS) assessments specifying the need for a therapeutic diet due to diagnoses such as type two diabetes mellitus, schizoaffective disorder, schizophrenia, dysphagia, and other chronic conditions. The care plans for these residents included interventions to provide diets as ordered, specifically to address their nutritional and medical needs. Despite these documented requirements, the dietary staff did not follow the prescribed menu substitutions for the RCS diet on the date in question. Interviews with dietary staff confirmed the failure to provide the correct dessert. The dietary aide responsible for placing desserts on trays acknowledged that only brownies or pureed brownies were served, and the assistant regional dietary staff member confirmed that residents on an RCS diet should have received fresh fruit instead. Review of the facility's policy on therapeutic diets further indicated that the facility was responsible for ensuring residents received diets as ordered, which did not occur in this instance.