Failure to Follow Menus and Dietary Orders for Multiple Residents
Penalty
Summary
The facility failed to follow its posted menus and dietary orders for nine residents reviewed, resulting in multiple instances where residents did not receive the food items, condiments, or supplements as specified on their dietary tickets and care plans. Residents with various medical conditions, including chronic kidney disease, dementia, diabetes, malnutrition, and dysphagia, were affected. For example, several residents did not receive butter or jelly with their breakfast toast, corn tortillas, or butterscotch pudding with lunch, despite these items being listed on the menu and dietary tickets. In some cases, residents specifically expressed their desire for these missing items, but they were not provided. Interviews and observations revealed that the dietary staff did not consistently provide menu items as ordered, and there were reports of missing condiments, desserts, and even entire meal components. Staff and residents reported that the food served often did not match the dietary tickets, and that substitutions were not always made when items were unavailable. On one occasion, due to a staff walkout and lack of kitchen resources, residents were served peanut butter and jelly sandwiches and oatmeal instead of the planned menu, and some dietary supplements and double protein orders were not provided. Staff also reported ongoing issues with missing items and late food service following this event. The report includes statements from dietary staff, CNAs, and residents confirming that menu items were frequently omitted, and that communication between dietary and nursing staff was insufficient to ensure residents received their prescribed diets. The Registered Dietician stated that the menu should be followed and that substitutions of equal nutritional value should be made if items are unavailable, but this was not consistently done. The deficiency was observed through interviews, record reviews, and direct observation of meal service.