Failure to Follow Prescribed Menus and Recipes for Therapeutic Diets
Penalty
Summary
The facility failed to ensure that planned menus and recipes were followed for residents on therapeutic diets during a lunch meal service. Specifically, a resident on a low fat and low cholesterol diet received tartar sauce instead of the prescribed lemon slice, as indicated on the facility's menu spreadsheet. Four residents requiring fortified diets did not receive the additional one ounce of margarine on their vegetables as specified for their nutritional needs. Additionally, three residents on mechanical soft texture diets were served fish prepared for dysphagia mechanical soft texture diets, which did not match the required flaked and moist fish with soft tomatoes. Five residents on dysphagia mechanical soft diets received fish that was not prepared according to the recipe, as the tomatoes were not pureed but served in pieces. These deficiencies were observed during a lunch meal distribution and confirmed through interviews with the Registered Dietitian, who acknowledged that staff did not follow the menu spreadsheet or recipes as required. Facility documents, including job descriptions and policies, indicated that staff are responsible for following prepared menus, accurately preparing special diets, and checking trays for accuracy before delivery. The failure to adhere to these protocols resulted in 13 residents not receiving meals that met their prescribed nutritional needs and food textures.