Failure to Serve Physician-Ordered Consistent Carbohydrate Diet
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic polyneuropathy, who was prescribed a consistent carbohydrate (CCHO) diet of 60-75 grams of carbohydrates per meal, was not served the physician-ordered diet. The resident's care plan and physician orders specified the CCHO diet, and the approved menu detailed specific serving sizes, including a 2-ounce portion of mashed sweet potatoes. However, during meal service, staff served the resident a 4-ounce portion of sweet potatoes, which exceeded the prescribed amount for the CCHO diet. The staff member responsible for plating the meal acknowledged serving the regular diet instead of the CCHO diet as indicated on the meal ticket. Interviews with the Dining Hospitality Coordinator, Certified Dietary Manager, and Dietitian confirmed that the staff did not follow the posted menu extensions and serving sizes, which are intended to prevent such errors. The facility's policy directed that the menu and serving sizes be followed as approved by the Registered Dietitian Nutritionist Supervisor or Lead Hospitality Coordinator. The failure to adhere to the prescribed diet and serving sizes resulted in the resident not receiving the ordered therapeutic diet.