Failure to Follow and Document Menu Changes, Resulting in Nutritional Deficiencies
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents, were prepared and followed as written, and that any changes were properly documented and communicated. Observations and interviews revealed that menu substitutions were not consistently recorded on the Menu Substitution Log, and residents were not notified of changes to the posted menu. The last documented substitution was over a month prior to the survey, and the substitution made did not meet the nutritional guidelines for a regular diet, resulting in insufficient servings of fruit on that day. Multiple residents did not receive the food and beverages listed on their tray tickets during observed meals. Instead, they were served alternative items without proper documentation or notification. Residents reported that the posted menu often did not match what was served, and that sometimes no substitute was offered when items were unavailable. Specific examples included residents not receiving fruit cocktail, mandarin oranges, chocolate milk, iced tea, or fortified mashed potatoes as listed, and their requests for these items were not fulfilled. Interviews with staff, including the Food Service Director and Registered Dietitian, confirmed that menu changes were not always communicated or documented, and that substitutions were not always of similar nutritional value. The Food Service Director indicated that food orders were sometimes altered by the corporate office to meet budget constraints, which contributed to the unavailability of menu items. As a result, the minimum daily meal pattern for a regular diet was not met on multiple days, with residents receiving fewer servings of fruits and vegetables than required.