Failure to Follow Menus and Document Substitutions During Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed and that any substitutions were properly documented and communicated to residents during meal service across all four halls reviewed. On the specified lunch service, residents did not receive all food items listed on the menu, specifically macaroni salad, and two residents on pureed diets did not receive the required pureed roll. Observations confirmed that trays were served without the macaroni salad or an immediate substitute, and the pureed roll was omitted for two residents with special dietary needs. Staff interviews revealed that the kitchen did not have macaroni salad available, and residents were not informed of the missing item at the time of meal service. Multiple grievances had been previously logged by residents regarding missing food items, incorrect meals, and incomplete trays, indicating a pattern of similar issues. During the observed lunch, staff acknowledged that substitutions were not offered at the time of meal service, and alternative items such as chips or mashed potatoes were only provided later in the afternoon as a snack, rather than as part of the meal. The dietary manager and dietitian confirmed that all menu items should have been served or substituted with items of equivalent nutritional value, and that documentation of substitutions should occur prior to meal service. However, the substitution log for the day in question was only completed after the meal, and residents were not notified of the changes in a timely manner. One resident with severe protein-calorie malnutrition and dysphagia, who required a mechanically altered diet, did not receive the prescribed pureed roll and reported not having received bread options in the past. Staff interviews indicated confusion and lack of communication regarding menu substitutions and the process for notifying residents. The facility's own policies required that menu changes be documented and reviewed by the dietitian, and that substitutions be of equivalent nutritive value, but these procedures were not followed during the observed meal service.