Failure to Provide Prescribed Low Sodium/Cardiac Diets to Residents
Penalty
Summary
The facility failed to ensure that three residents received their prescribed two-gram sodium (low sodium) and/or cardiac diets as ordered by their physicians. Medical record reviews showed that these residents had significant diagnoses such as type two diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, and hypertensive heart disease, all of which required careful dietary management. Physician orders and care plans for these residents specifically indicated the need for low sodium or cardiac diets, and these requirements were documented in their nutritional assessments and care plans. During a review of the facility's menu and direct observation of meal service, it was found that the lunch menu for a specific day required residents on a two-gram sodium or cardiac diet to receive chicken with sautéed mushrooms instead of mushroom gravy. However, observation of the steam table and tray line revealed that no sautéed mushrooms were available, and all residents, including those on restricted diets, were served chicken with mushroom gravy. Only one resident received a different gravy due to a dislike or allergy, not due to dietary restrictions. Interviews with dietary staff and the dietary consultant confirmed that the correct menu modification for residents on therapeutic diets was not followed, and the error was attributed to oversight. Review of the facility's policy indicated that meals should be checked against the therapeutic diet spreadsheet to ensure accuracy, but this procedure was not followed, resulting in the deficiency. This issue affected three residents directly and had the potential to impact an additional six residents identified as being on similar therapeutic diets.