Failure to Provide Prescribed Carbohydrate-Controlled Diet
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral infarction, sleep apnea, multifocal motor neuropathy, and polyneuropathies, was not provided with the prescribed carbohydrate-controlled, low concentrated sweet (LCS) diet. During a lunch observation, the resident was served apple juice, which was not compliant with his dietary order for sugar-free beverages. The resident confirmed he consumed whatever was provided, and the meal ticket indicated he should have received a diet beverage and sugar-free hot chocolate. The certified nursing assistant stated she only checks the name on the meal ticket, while the cook is responsible for assembling the tray based on the ticket. The dietary manager confirmed that the resident should not have received apple juice and that the dietary flowsheet specified diet beverages for those on LCS diets. The cook provided apple juice, mistakenly believing it was high in fiber, despite the resident's physician and spouse preferring sugar-free options. The resident's care plan and physician orders both specified a no added salt/carb-controlled diet with no additional sweets, and the facility's policy required adherence to documented diet orders. The failure to follow the prescribed diet was identified through observation, interview, and record review.