Failure to Provide Prescribed Therapeutic Diets and Follow Approved Menu
Penalty
Summary
Surveyors identified that the facility failed to provide prescribed therapeutic diets and did not follow the approved menu for residents requiring specialized diets. Specifically, one resident on a mechanical soft diet was observed receiving roast beef cut into pieces or chunks approximately 0.5 inches in size, rather than the ground meat specified in the facility's menu spreadsheet. Additionally, this resident was served diced or chopped chicken instead of ground meat, as required. The Certified Dietary Manager (CDM) and Speech Language Pathologist (SLP) both confirmed that the menu breakdown called for ground meats, but the facility did not offer ground diets, instead providing bite-sized or chopped meats for mechanical soft diets. Another resident with diagnoses including Type 2 diabetes and chronic kidney disease was prescribed a carbohydrate-controlled, high-protein diet with regular texture and thin consistency. Observations revealed that this resident received meals inconsistent with the prescribed diet, such as two slices of wheat bread and two strips of bacon for breakfast, and two rolls for lunch instead of the specified breadstick and cauliflower. The CDM acknowledged that the resident received too much bread and bacon, and that bacon is not permitted on the CKD5 diet. The CDM also stated that he substituted rolls for breadsticks due to unavailability and used a high-protein diet in place of the specific CKD5 diet, as the menu and electronic health record (EHR) did not match. Interviews with dietary staff, including the CDM, Dietetic Technician (DTR), and the facility's Dietitian, revealed a lack of alignment between the EHR diet orders and the food service supplier's menu spreadsheets. Staff admitted to not having reviewed the new menu breakdowns and to making substitutions or using alternative diets when the prescribed diet was not available or did not match the menu. The Dietitian confirmed that this mismatch had occurred previously and required customization, but there was no clear process to ensure residents consistently received the correct therapeutic diets as ordered by their physicians.
Plan Of Correction
Resident #1 prescribed therapeutic diet order was reviewed and updated per physician order. 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 prescribed order is being followed, and to ensure the facility is following the menu for residents on a therapeutic diet. The Administrator educated the CDM (Certified Dietary Manager) on ensuring that prescribed therapeutic diet orders are being followed and ensuring the menu is being followed for residents on a therapeutic diet. The Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that prescribed therapeutic diet orders are being followed and that 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.