Failure to Follow Posted Menus and Document Meal Substitutions
Penalty
Summary
The facility failed to follow the posted menus for residents on both regular and modified diets during two consecutive lunch meals. On the first day, residents were served the meal scheduled for the previous day, and on the second day, they received the meal that was supposed to be served the day before, rather than the meals listed on the posted menu. There was no indication of any approved or posted menu changes for these deviations, except for a single substitution of mushrooms with sautéed onions and bell peppers, which was properly documented. Observations confirmed that the meals served did not match the planned menu, and no signs were posted to inform residents of the changes. Interviews with facility staff, including the administrator, dietetic technician registered (DTR), and dietary manager (DM), revealed a lack of awareness and oversight regarding the requirement to serve meals as posted and to document any changes on the Menu Substitution Approval Form. The DM acknowledged the error in serving the wrong meals and admitted that the required documentation and posting of menu changes were not completed. Review of facility policy confirmed that menus should be served as written unless an emergency arises, and all substitutions must be documented and reviewed by the registered dietitian (RD) or DTR.