Failure to Follow Diet Spreadsheets and Menu Orders for Therapeutic Diets
Penalty
Summary
Food and Nutrition Services staff failed to follow the facility's Cook's spreadsheet and diet orders for multiple residents on a controlled carbohydrate (CCHO) diet. During a lunch meal observation, two residents with diabetes mellitus type 2 were served cherry crisp for dessert instead of fruit, as required by the CCHO diet outlined in the facility's diet spreadsheet. The residents' medical records and physician orders confirmed their need for a CCHO diet, and the Registered Dietitian (RD) verified that the correct dessert should have been fruit. There was no documentation or posting regarding any changes to the planned menu, and the facility could not provide a log of such changes. Additionally, three residents did not receive gravy with their pot roast meat, contrary to the instructions on the meal tickets and the diet spreadsheet, which specified that both mechanical soft and pureed diets should include gravy with the pot roast. The RD confirmed that the meals should have included gravy, as indicated in the spreadsheet. The facility's policy and procedure required that diet spreadsheets be followed for regular and therapeutic diet orders, but these were not adhered to during the observed meal service.