Failure to Follow Therapeutic Diet Menus and Portion Sizes
Penalty
Summary
The facility failed to ensure that therapeutic diets were provided according to the prescribed menu and physician orders during lunch meals on two consecutive days. Specifically, three residents on a Consistent Carbohydrate (CCHO) diet received pineapple Bavarian cream square instead of the prescribed pineapple tidbits, and another resident on the same diet received pudding instead of the correct CCHO dessert. The facility's menu spreadsheet indicated that pineapple tidbits should have been served, and both the Certified Dietary Manager (CDM) and Registered Dietitian (RD) confirmed that the observed desserts did not comply with the menu requirements for CCHO diets. Additionally, during a meal service, fifteen residents on fortified diets did not receive the required super soup, which is intended to provide extra calories and nutrients for those unable to consume adequate amounts of food. The menu spreadsheet specified that super soup should be provided for fortified diets, but it was omitted during the meal service. Furthermore, two residents on large portion diets received only three ounces of meat instead of the four ounces specified in the menu spreadsheet. The RD explained that large portion diets are necessary for residents who need more protein or have specific preferences, and the correct portion size is essential to meet their nutritional needs. These failures were observed during direct dining and meal service observations, and were acknowledged by both the CDM and RD. The facility's own diet manual and job descriptions for dietary staff require strict adherence to menu specifications and portion sizes for therapeutic diets. The deficiencies had the potential to compromise the medical and nutritional status of a significant number of residents who received meals from the facility's kitchen.
Plan Of Correction
Corrective Action for Affected Residents: On 4/23/25, the Registered Dietitian reviewed the nutritional status of Residents 11, 21, 35, and 17 who received incorrect CCHO desserts, and Residents 1, 2, 3, 7, 15, 18, 20, 21, 25, 28, 30, 38, 39, 41, and 396 who did not receive super soup for fortified diets, and Residents 6 and 17 who received incorrect portion sizes. No adverse effects were identified. The Certified Dietary Manager immediately corrected portion sizes and therapeutic diet components for all affected residents. Identifying other Residents having the Potential to be Affected: On 4/23/25, the Registered Dietitian conducted a comprehensive review of all residents receiving therapeutic diets to ensure proper menu items and portion sizes were being provided. The CDM reviewed all current therapeutic diet orders against the menu spreadsheet to ensure alignment. Measures put into place or Systemic Changes: 1. The CDM will in-service all dietary staff: - Proper portion sizes for therapeutic diets - Following menu spreadsheets accurately - Importance of therapeutic diet compliance - Proper documentation of menu substitutions 2. Kitchen staff will measure protein portions using standardized serving utensils and scales to ensure accurate portions. Plan to Monitor Performance: 1. The CDM or designee will audit 10 therapeutic diet trays daily for 2 weeks, then 3x/week for 2 weeks, then weekly for 1 month to ensure compliance with menu spreadsheet and proper portions. 2. The RD will conduct weekly random audits of 5 therapeutic diet trays for 4 weeks, then monthly for 2 months. 3. Results of all audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee quarterly by the Food Service Director. The QAPI committee will analyze data for patterns and trends and make recommendations for continued monitoring or modification of plan as needed until substantial compliance is achieved and maintained. All corrective action to be completed by 5/26/25. 2. The Maintenance Supervisor will be in-serviced by the CDM on proper ice machine cleaning procedures per manufacturer's guidelines. 3. The Director of Nursing will in-service all nursing staff on proper temperature monitoring and documentation for resident unit refrigerators/freezers. Plan to Monitor Performance: 1. The CDM or designee will conduct weekly audits for 4 weeks, then monthly for 12 months of: - Ice machine cleanliness - Equipment condition - Food storage practices - Temperature logs - Food labeling compliance 2. The Director of Nursing or designee will audit resident unit refrigerator/freezer temperature logs daily for 4 weeks, then weekly for 12 months. 3. Results of all audits will be reported to the Quality Assurance Performance Improvement (QAPI) Committee quarterly for review and additional interventions as needed until substantial compliance is achieved and maintained for 3 consecutive months. All corrective action to be completed by 5/26/25.