Failure to Provide Prescribed Therapeutic Diets to Diabetic Residents
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for two residents diagnosed with Type 2 Diabetes who were prescribed a carbohydrate-controlled (diabetic) diet and received scheduled insulin. Both residents were observed receiving and consuming cornbread as part of their lunch meal, despite their dietary cards and the facility's dietary spreadsheet indicating that cornbread should not be served to individuals on a diabetic diet. Staff interviews confirmed that the dietary spreadsheet specifically marked cornbread as 'No' for diabetic diets, and both the registered dietitian and kitchen cook acknowledged that these residents should not have received cornbread. Record reviews and staff interviews further revealed that the dietary staff were expected to follow the prescribed therapeutic diets and use the dietary spreadsheet to guide meal preparation. However, the failure to adhere to these protocols resulted in the residents receiving food items not permitted on their prescribed diets. The Director of Nursing confirmed that the expectation was for staff to follow the prescribed diets and acknowledged that the residents should not have received cornbread.