Failure to Provide Diabetic-Appropriate Diet and Adhere to Dietary Orders
Penalty
Summary
A deficiency was identified when a diabetic resident did not receive a well-balanced diet that met their prescribed dietary needs. During breakfast, the resident was served a tray containing regular sugar and regular jelly, despite being on a Low Concentrated Sweets (LCS) and No Added Salt (NAS) diet. The tray also lacked a meat option, a choice of Vitamin C juice, sugar substitutes, and sugar-free jelly, all of which were specified in the resident's diet order. The resident, who has diabetes, hypertension, hemiplegia, protein-calorie malnutrition, and hyperlipidemia, reported not using the regular sugar or jelly and stated that diabetic-appropriate alternatives were not provided on his tray. At lunch, the same resident received a tray with black beans, rice, chopped baked chicken, unfrosted banana cake, and orange drink, but the tray was missing navy bean soup, buttered carrots or any vegetable, coffee or tea, and sugar substitutes, as outlined in the diet card. The resident's food preferences also indicated a dislike for rice and desserts or sweets, yet these items were present on the tray. Interviews with dietary staff confirmed that the resident should have received diabetic-appropriate items, such as sugar substitutes and diabetic jelly, and that substitutions for menu items were not properly communicated or executed, resulting in missing or incorrect food items. Record reviews showed that the resident's care plan and physician's orders required a therapeutic diet tailored to his medical conditions, including diabetes and risk for nutritional deficits. The facility's own policies mandated that residents receive nutritional care consistent with their assessments and dietary orders. However, observations and staff interviews revealed that the resident's dietary needs and preferences were not consistently met, leading to the identified deficiency.