Failure to Serve Menu Items as Planned
Penalty
Summary
Facility staff failed to follow the planned menu for residents, as evidenced by observations and menu reviews. On the specified lunch meal, the planned menu included turkey tetrazzini, buttered peas, bread and margarine, fruited gelatin, and milk. However, during the puree process and meal service, bread and margarine were not pureed or served, despite being listed on the menu and selected by residents as a meal choice. Observations confirmed that no bread and margarine were provided to residents, including those on pureed diets. Staff interviews with the Dietary Manager and Dietician confirmed that bread and margarine should have been served according to the menu and resident selections. Facility policy requires that meals be served as listed on the menu and checked against therapeutic diet spreadsheets, which was not followed in this instance.