Failure to Serve Menu Meal as Written for Resident with Malnutrition
Penalty
Summary
The facility failed to serve a lunch meal as written on the menu for one sampled resident who had a diagnosis including unspecified protein calorie malnutrition and severely impaired cognition. The resident had a physician order for a regular diet, regular texture, and regular consistency. According to the facility's posted menu, the lunch meal was supposed to include chicken parmesan, spaghetti, tomato sauce, Italian mixed vegetables, garlic roll, margarine, Italian ice, and whole milk. However, the resident's meal tray slip listed substitutions, including fried chicken with no sauce, noodles with no gravy, and other items. Observation revealed the resident was served plain steamed chicken thigh, Italian mixed vegetables, garlic bread, iced tea, and Italian ice, rather than the chicken parmesan specified on both the menu and the tray slip. Interviews with the resident's family member, the Administrator, and the Director of Dietary confirmed that the resident was not served the chicken parmesan as indicated. The family member reported that the resident was often not served what was indicated on the meal tray slip. Both the Administrator and the Director of Dietary acknowledged that, despite the resident's preference for no sauces or gravy, the resident should have been served chicken parmesan without sauce, as per the menu and tray slip. The Director of Dietary also stated that cooks typically set aside unsauced chicken parmesan for residents who prefer no sauces, but this was not done in this instance.