Failure to Provide Prescribed and Complete Meals per Menu and Meal Tickets
Penalty
Summary
The facility failed to provide residents with meals that met their prescribed dietary needs and preferences as outlined in their meal tickets and the facility menu. For one resident with hemiplegia, vascular dementia, and other conditions, the meal ticket specified a mechanical diet including glazed ham, green beans, rice pudding, au gratin potatoes, and a wheat dinner roll. However, the resident was served brussels sprouts instead of green beans, and the green beans were not prepared at all. Staff confirmed the discrepancy and were unable to explain why the correct vegetable was not provided, despite the meal ticket indicating otherwise. Another resident, with Alzheimer's disease, dementia, and dysphagia, was ordered a regular diet with puree texture. The meal ticket and menu called for pureed glazed ham, brussels sprouts, au gratin potatoes, rice pudding, and bread. At the time of service, only pureed ham and brussels sprouts were available and served; the other pureed items were not prepared. The kitchen manager acknowledged the missing items and stated that the equipment needed to prepare them was unavailable at the time. The diet technician confirmed that all items on the meal ticket should have been served. Facility policy requires that menus be followed as written unless changed for preference or unavailability, but no such changes were documented.