Failure to Provide Pureed Dinner Rolls to Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure that residents on pureed diets received a pureed dinner roll during the lunch meal, as required by the menu and residents' dietary orders. During an initial kitchen tour and subsequent meal preparation observation, it was noted that no pureed dinner rolls were provided to any of the eight residents on pureed diets. The Dietary Manager confirmed that the lunch meal was supposed to include herbed turkey, California blend vegetables, mashed potatoes and gravy, cookies, and dinner rolls, but the pureed version of the dinner roll was omitted for those on pureed diets. Interviews with the Dietary Manager and Registered Dietitian revealed that the omission was due to staff forgetting to prepare the pureed dinner rolls. The Registered Dietitian emphasized the importance of serving the pureed bread to meet residents' nutritional needs, specifically carbohydrate intake, and clarified that a larger portion would be necessary if the bread was combined with other items. The facility's menu and policy required all food items, including pureed dinner rolls, to be served as listed, but this was not followed for the lunch meal in question.