Failure to Serve Dietitian-Approved Menus to Residents
Penalty
Summary
The facility failed to ensure that meals were served according to the dietitian-approved menu, affecting multiple residents and potentially all residents who consumed meals at the facility. Observations and interviews revealed that several residents did not receive all components of the prescribed meals, such as milk and cereal, despite these items being listed on the approved menus and required by the meal tickets. Staff confirmed that unless the meal tickets specifically indicated certain items, such as milk or cereal, these were not provided, even though the menu required them. This practice was confirmed by both the Dietary Manager and the Administrator. Several residents with significant medical histories, including dementia, malnutrition risk, and other chronic conditions, were directly impacted. For example, one resident at risk for malnutrition and with recent weight loss did not receive milk or cereal as required by the menu. Another resident, who was malnourished and required finger foods and health shakes, did not receive all menu items, including cereal and milk, during observed meals. Similar deficiencies were observed for other residents, including those with Alzheimer's disease, multiple sclerosis, and other serious diagnoses, who did not receive the full menu as approved by the dietitian. Additionally, there were instances where the meals served did not match the menu due to substitutions or omissions, such as serving a taco instead of a cheeseburger or omitting buttered carrots from a lunch meal. Staff interviews indicated that some menu items were not provided due to budget constraints or lack of clarity on meal tickets. The dietitian and dietary staff confirmed that the approved menus were not consistently followed, and some residents did not have completed nutritional assessments or care plans at the time of the survey.