Failure to Follow Menus and Document Substitutions During Meal Service
Penalty
Summary
The facility failed to ensure that its menus were followed and that any substitutions were properly documented and communicated to residents. On the date in question, multiple residents did not receive all food items listed on the lunch menu, specifically macaroni salad, and two residents on pureed diets did not receive the required pureed roll. Observations confirmed that trays were served without these items, and staff interviews revealed that the kitchen did not have macaroni salad available and did not inform residents of the missing item or provide an immediate substitute during the meal service. Resident records indicated that at least one resident had significant nutritional needs, including severe protein-calorie malnutrition and dysphagia, requiring a mechanically altered diet. The care plan for this resident specified that the prescribed diet should be followed. Despite this, the resident did not receive the pureed roll as ordered, and staff acknowledged the oversight. The facility's grievance log also documented multiple prior complaints about missing food items, incomplete trays, and lack of communication regarding menu changes. Staff interviews and policy reviews confirmed that substitutions should be of equivalent nutritive value, documented prior to meal service, and communicated to residents. However, the substitution log for the meal in question was completed after the fact, and residents reported that substitutes were only offered later in the afternoon, not during the meal. The dietitian and dietary manager both stated that all menu items should be served as planned or with appropriate substitutions at the time of service, and that failure to do so could impact residents' nutritional intake.