F0808

D

Failure to Follow Physician-Ordered Therapeutic Diet

San Antonio, Texas Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to provide a physician-ordered therapeutic CCHO renal diet to a resident. The resident had diabetes and minimal cognitive impairment, and her care plan and physician orders specified a CCHO renal diet with regular texture and thin liquids. The resident’s individualized CCHO-renal menu for a specific lunch called for baked chicken breast with chicken gravy, orange twist, buttered chopped spinach, rice, buttered dinner roll, sugar cookies, and appropriate beverages. However, the facility’s weekly menu calendar and the posted daily menu listed fried chicken, spinach, mashed potatoes, sugar cookies, and a buttered dinner roll for that meal, which did not match the resident’s therapeutic menu.

During observation and interview at the lunch meal, the resident was actually served baked chicken, mashed potatoes, egg noodles, a sugar cookie, and a buttered dinner roll, and had eaten about half of the meal, including the mashed potatoes and noodles. The resident stated she was diabetic, understood she should limit carbohydrate intake, and reported she was often served items not on her menu or that she should not have, and that prior complaints had not helped. The DON confirmed the resident was on a CCHO diet and should not have received mashed potatoes. The Dietary Manager confirmed the resident should have received rice instead of mashed potatoes, that egg noodles were not on the menu, and that the cook had substituted egg noodles for rice without following the menu or documenting the substitution per policy. Facility policies required meals to be provided according to physician orders, the facility diet manual, and menu spreadsheet, and required any menu variations to be documented and reviewed by the dietitian, which did not occur in this case.