Failure to Follow Prescribed Diabetic Diet and Menu for Resident
Penalty
Summary
The facility failed to ensure that prescribed menus were followed to meet the nutritional needs of a diabetic resident, resulting in the resident not receiving appropriate dietary items as ordered. During breakfast, the resident received a tray containing regular sugar and regular jelly, without the required sugar substitutes or diabetic jelly, despite being on a Low Concentrated Sweets (LCS) and No Added Salt (NAS) diet. The breakfast tray also lacked a meat option and a choice of Vitamin C juice, both of which were specified on the resident's diet card. The resident, who has diabetes, hypertension, hemiplegia, protein-calorie malnutrition, and hyperlipidemia, reported not using the regular sugar or jelly and not receiving diabetic alternatives on his tray. At lunch, the resident's tray did not include the planned navy bean soup, buttered carrots or any vegetable, coffee or tea, or sugar substitutes. Instead, the tray contained black beans, rice, chopped baked chicken, unfrosted banana cake, and orange drink. The lunch diet card specified that the resident should have received navy bean soup, baked chicken, rice, buttered carrots, banana cake, coffee or tea, and sugar substitute. The facility's menu substitution log indicated that buttered carrots were substituted with peas and banana cake with yellow cake without frosting, but peas were not present on the tray. Interviews with dietary staff confirmed that the resident should have received diabetic-appropriate items, including sugar substitutes and diabetic jelly, which were available in the facility. The dietary manager acknowledged that the resident was served regular sugar and jelly in error and that the planned vegetable substitution for lunch was not provided. The resident's food preferences also indicated a dislike for desserts, sweets, and rice, yet these items were included on his tray. The facility's assessment documented the need to provide individualized dietary requirements, but these were not met for this resident.