Failure to Follow Prescribed Menu and Document Substitutions for Pureed Diets
Penalty
Summary
The facility failed to follow the prescribed menu for one observed lunch meal, specifically for residents on pureed diets. During the lunch service, pureed dinner rolls were not prepared or served to residents who required pureed meals, and greens were substituted for broccoli florets without proper documentation or posting of the substitution. Both the Dietary Manager and a visiting Dietary Manager from a sister facility confirmed that the omission of the pureed dinner roll was due to staff oversight and that facility policy requires all residents to receive the same meal and for any substitutions to be posted and documented. Review of the facility's menu confirmed that the planned meal included pork roast loin, buttered broccoli florets, boiled potato, dinner roll, and chocolate pudding. The facility's policy on menu changes and substitutions requires that any variation from the planned menu be documented and reviewed by the Dietician, with substitutions made using foods of equivalent nutritive value. No documentation or posting of the substitution was observed, and the Dietary Managers acknowledged the importance of following the menu to ensure residents receive adequate nutrition.