Failure to Follow Menu and Diet Specifications for Specialized Diets
Penalty
Summary
The facility failed to follow standardized recipes and menu instructions for residents on specialized diets during a lunch service. Six residents on a pureed diet received only half a cup of enchilada instead of the required one cup, as specified in the facility's portion and serving guide. The cook responsible for preparing the meal was unaware of the correct portion size and did not consult the spreadsheet, resulting in residents receiving less food than prescribed. Dietary staff responsible for reading and calling out diet orders also did not notice the discrepancy in portion size, and the registered dietitian confirmed that the meal tickets indicated the correct amount, which was not followed. For residents on a Controlled Carbohydrate (CCHO) diet, 23 individuals received four ounces of Spanish rice instead of the two ounces specified for their diet. Both the cook and dietary aide were unaware that the CCHO diet required a reduced portion of rice compared to the regular diet. The registered dietitian and dietary supervisor confirmed that the menu and spreadsheet clearly indicated the correct portion sizes, and the facility's policy emphasized the importance of adhering to these portions for blood sugar control. Additionally, six residents on a soft and bite size diet received cheese enchiladas that were not cut into the required ½ x ½ inch pieces, as per the facility's policy and IDDSI guidelines. The cook cut the enchiladas into inconsistent sizes using a spatula during service, rather than preparing them in advance to the correct specifications. The issue was identified during a tray check, and the trays were returned to the kitchen for correction. The registered dietitian and dietary supervisor confirmed that the food was not prepared to the required texture and size prior to service, as mandated by facility policy and international guidelines.