Failure to Provide Appropriate Diets for Residents with Special Dietary Needs
Penalty
Summary
The facility failed to ensure that residents on specialized diets, including controlled carbohydrate diets (CCD), liberalized renal diets, and renal diets with regular or mechanically altered consistency, received the appropriate food items as specified in the facility's diet spreadsheets and menu guidelines. During a lunch meal service, observations revealed that all residents on regular or mechanically altered diets were served the same items—herb roasted pork loin, candied sweet potatoes, and buttered cabbage—regardless of their prescribed dietary restrictions. There were no plain sweet potatoes or buttered noodles available on the steam table for those requiring alternatives, and the dietary staff confirmed that brown sugar had been added to all sweet potatoes, making them unsuitable for CCD and renal diets. Interviews with dietary staff and the dietary manager revealed that the diet spreadsheets, which detailed the specific meal modifications required for each diet type, were not accessible or followed during meal service. The dietary manager admitted to not double-checking that residents received the correct items and stated that the facility typically had liberal diets. The dietitian confirmed that the spreadsheets should have been followed. Additionally, the facility's policy did not include guidance on following diet spreadsheets. This deficiency affected a significant number of residents identified as requiring specialized diets.