Failure to Follow Prescribed Menus and Dietary Requirements During Meal Service
Penalty
Summary
During a lunch meal service, the facility failed to follow prescribed menus and dietary requirements for multiple residents. One resident on a mechanical soft (MS) texture and small portion diet received an incorrect portion size of meatball, being served 1/3 cup instead of the required 3/8 cup. Another resident with MS, controlled carbohydrate (CCHO), and renal diets was served brown rice instead of the prescribed wheat pasta, despite wheat pasta being available. Additionally, a resident on an MS diet received a parsley sprig garnish instead of parsley flakes, which was specified in the menu. Six other residents did not receive any parsley garnish with their meals, contrary to the menu requirements. Interviews with the Dietary Supervisor and Registered Dietitian confirmed that dietary staff did not follow the facility's menu spreadsheet or use the correct scoop sizes and substitutions. The Registered Dietitian also noted that providing a whole parsley sprig instead of flakes to a resident on an MS diet could pose a choking risk. Job descriptions for dietary staff and the dietitian outlined responsibilities to prepare and serve food according to planned menus, portion control procedures, and special diet orders, which were not adhered to during this meal service.