Failure to Follow Approved Menus and Diet Orders During Meal Service
Penalty
Summary
The facility failed to follow the approved, dietitian-reviewed menu for multiple residents with specific dietary needs during a lunch meal service. Eleven residents on a pureed diet did not receive pureed bread as required, and instead only received pureed beef stroganoff, pureed noodles, and pureed peas, with no bread substitute provided. Additionally, three residents on a renal diet and fifteen residents on a heart healthy diet were served beef stroganoff instead of the prescribed salisbury steak. The dietary manager confirmed that the extended menu with detailed diet listings was not easily accessible and admitted to forgetting to provide pureed bread and not realizing the need for a different entrée for renal and heart healthy diets. Further, the recipe for beef stroganoff was not followed for fifty-five residents on regular and mechanical soft diets, as the dietary manager added approximately five cups of extra cream sauce to the beef without following the approved recipe. The registered dietitian confirmed that the additional cream sauce increased the fat content of the dish, which was not appropriate for residents on heart healthy diets. These actions resulted in residents not receiving meals that met their prescribed nutritional needs as outlined in the approved menu.