Failure to Follow No Added Salt Diet Orders for Multiple Residents
Penalty
Summary
The facility failed to follow its own menu and nutritional guidelines by providing extra packets of salt to residents who were prescribed No Added Salt (NAS) diets. Multiple residents with medical conditions such as hypertension, heart disease, and impaired cognition were observed to have received salt packets on their meal trays, despite clear dietary orders specifying NAS diets. This was confirmed through record reviews, resident interviews, and direct observation of meal service, where kitchen staff routinely added salt and pepper packets to all trays without checking individual dietary restrictions. Residents affected included those with intact cognition who reported receiving extra salt packets, as well as residents with impaired cognition who were unable to advocate for themselves. The dietary orders for these residents specifically required NAS diets due to their medical conditions, including hypertension, heart failure, and atherosclerotic heart disease. The facility's menu and policy also indicated that NAS diets should not include salt packets, and that dietary staff are responsible for ensuring therapeutic diets are prepared and served as ordered. Interviews with the Dietary Service Supervisor and the Director of Nursing confirmed that the kitchen staff did not check tray tickets for NAS diet orders and acknowledged that this practice could negatively impact residents' medical conditions. The deficiency was identified through a combination of record review, resident council feedback, direct observation of meal trays, and staff interviews, all of which demonstrated a failure to adhere to prescribed dietary restrictions for residents requiring NAS diets.