Failure to Follow Prescribed Menu for Mechanically Altered Diet
Penalty
Summary
The facility failed to follow the prescribed menu for a resident requiring a mechanically altered diet. Specifically, the resident, who had a history of myocardial infarction and severe cognitive impairment, was ordered to receive a ground chicken fried chicken entree for lunch. Instead, the resident was served a ground beef patty. The resident's care plan and physician orders specified a mechanically altered diet, and the lunch meal ticket indicated ground chicken fried chicken as the correct entree. Staff interviews confirmed that the resident did not receive the correct meal, and the dietary staff member responsible admitted to substituting ground beef for ground chicken to ensure enough chicken was available for residents on regular diets who requested seconds. The dietary manager was unaware of the substitution until after the meal was served and stated that the menu should have been followed for all diet textures. The charge nurse responsible for checking the resident's tray did not recognize the substitution and only became aware of the issue after it was pointed out by a state surveyor. The facility's policy required that menus be developed and prepared to meet resident choices, but this was not followed in this instance, resulting in the resident not receiving the ordered meal.