Failure to Follow Prescribed Menus and Therapeutic Diet Orders
Penalty
Summary
The facility failed to follow prescribed menus and therapeutic diet orders for two residents, resulting in noncompliance with federal regulations regarding menu preparation, nutritional adequacy, and adherence to physician-ordered diets. For one resident on a mechanical soft diet, observations revealed that meals provided included diced or chopped meats rather than the ground meats specified in the facility's menu spreadsheet. The Certified Dietary Manager (CDM) and Speech Language Pathologist (SLP) confirmed that the menu breakdown called for ground meats, but the facility was serving bite-sized or chopped meats instead, citing their interpretation of the International Diet Standardization Initiative (IDDSI) guidelines. The CDM stated that the facility did not offer ground diets, despite the menu indicating otherwise. Another resident with a diet order for a carbohydrate-controlled, high-protein diet with regular texture and thin consistency was observed receiving meals that did not match the prescribed diet. The resident received two slices of bread and two strips of bacon for breakfast, and two rolls for lunch, which exceeded the menu's specified portions and included items not permitted on certain therapeutic diets, such as bacon for a CKD5 diet. The CDM admitted to substituting rolls for breadsticks and providing more bread than allowed, acknowledging these as mistakes. Additionally, the diet orders in the electronic health record (EHR) did not match the food service supplier's menu spreadsheets, leading to confusion and inconsistency in meal preparation. Interviews with dietary staff, including the CDM, Dietetic Technician (DTR), and the facility's Dietitian, revealed a lack of communication and review of the new menu spreadsheets. The CDM and DTR were not fully aware of the menu breakdowns or how to match them to resident diet orders, and the Dietitian confirmed that discrepancies between the EHR and menu spreadsheets had occurred previously. The facility's process for reviewing and updating menus, as well as ensuring that staff were trained on new menu guidelines, was insufficient, resulting in residents not consistently receiving meals that met their prescribed dietary needs.
Plan Of Correction
The Registered Dietician reviewed and updated the facility's menu to ensure a therapeutic diet is being provided for Resident #45 and Resident #1. A quality audit of current residents on a therapeutic diet was conducted to ensure the facility is following the menu for residents on a therapeutic diet. The Administrator educated the CDM (Certified Dietary Manager) on ensuring the menu is being followed for residents on a therapeutic diet. Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure the menu is being followed for residents on a therapeutic diet. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.