Failure to Follow Prescribed Consistent Carbohydrate Diet Orders
Penalty
Summary
Three residents with diagnoses of type 2 diabetes were prescribed consistent carbohydrate diets, with specific meal orders indicating they should receive a half slice of garlic toast. During a meal service observation, the surveyor noted that these residents were instead served a full slice of garlic toast, contrary to their dietary orders. The tray cards for each resident, which the dietary staff referenced, clearly indicated the correct portion size, but this instruction was not followed. Interviews with the dietary staff member responsible for meal preparation revealed that the staff did not notice the tray card instructions specifying the half slice portion. The Dietary Manager confirmed that diet orders are to be followed as written. The facility's policy also states that residents on therapeutic diets should not receive food outside their prescribed orders unless approved by the appropriate clinical staff.