Failure to Provide Menu-Specified Protein Item to Residents
Penalty
Summary
The facility failed to provide the pork sausage patty as indicated on the menu and meal tickets for two residents during breakfast service. Both residents had meal tickets and dietary profiles that specified a regular diet with no restrictions or dislikes for pork or sausage, and both were assessed as needing adequate protein and calorie intake due to their medical conditions. Observations confirmed that the breakfast trays delivered to these residents did not include the sausage patty, despite it being listed on their meal tickets and the facility's approved menu. For the first resident, documentation showed diagnoses including generalized muscle weakness, anemia, and chronic kidney disease, with a care goal to maintain optimal oral intake and avoid significant weight change. The resident was cognitively intact and had no dietary restrictions. During the breakfast meal observation, the resident expressed disappointment at not receiving the sausage patty. The Dietary District Manager (DDM) and Registered Dietitian (RD) confirmed that the resident should have received the sausage patty as per the menu and meal ticket, and that staff are responsible for ensuring trays match the meal tickets before delivery. The second resident had diagnoses of muscle weakness, respiratory failure, and COPD, with a care plan to improve nutritional status and tolerate a high-protein diet. The resident's nutrition assessment indicated moderate protein-calorie malnutrition and a goal to gain weight. The breakfast tray delivered did not contain the sausage patty, and the resident expressed feeling disheartened. Staff interviews revealed that the sausage patty was not included as required, and the DDM and RD confirmed this was not in accordance with the resident's dietary order. The failure to provide the specified menu item was observed and acknowledged by dietary and nursing staff.