Failure to Follow Therapeutic Diet Orders and Provide Ordered Nutritional Supplements
Summary
Surveyors found that the facility failed to follow physician-ordered therapeutic diets and provide ordered supplements. One resident on a controlled pureed diet with honey-thick liquids, who had severe cognitive impairment and was care planned for risk of compromised nutritional status, was not served a vegetable at lunch; her tray contained only pureed chicken, a pureed starch, and possibly a pureed bread covered in gravy, despite the menu listing a pureed vegetable (broccoli on one day and peas on another). During tray line observation, no pureed vegetables were present on the line even though the pureed menu specified a pureed vegetable. The Dietary Manager and Registered Dietitian were informed of the missing pureed vegetable and acknowledged the absence. The facility also failed to provide physician-ordered Magic Cup nutritional supplements as specified. One resident with varying dietary intake and a care plan for compromised nutritional status had an order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner, but during a breakfast observation the Magic Cup was listed on the meal ticket and not provided. Another resident observed at the same breakfast also had a Magic Cup ordered but did not receive it. A third resident with moderate cognitive impairment had an order for a 4 oz Magic Cup with lunch; during lunch observations, this resident’s ticket read Magic Cup, but she was given a chocolate ice cream cup and ate coconut cream pie for dessert instead of the ordered supplement, while the MAR documented 100% consumption of a Magic Cup on consecutive days. The RD and Dietary Manager stated that dietary staff were responsible for providing Magic Cups but could not explain why residents in the dining room did not receive them.
Plan Of Correction
Dietary Services CFR(s): 400.141(1)(i), FS Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required N0407 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R] . RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] and resolving any variances that may occur.
Penalty
Surveyors found that the facility did not provide prescribed therapeutic diets or follow the approved menu for two residents on specialized diets. One resident on a mechanical soft diet received chopped meats instead of ground, while another with diabetes and CKD received meals inconsistent with their diet order, including excess bread and bacon. Dietary staff confirmed discrepancies between diet orders and menu spreadsheets, leading to substitutions and mismatched diets.
Two residents in a facility did not receive their prescribed therapeutic diets, leading to deficiencies in dietary services. One resident, requiring a pureed diet and double protein portions, was given a mechanical soft diet due to staff's lack of awareness of dietary changes. Another resident, needing double protein portions, received only a single portion despite the meal ticket indicating otherwise. The facility lacked a policy for ensuring dietary orders were followed, resulting in residents not receiving appropriate nutrition.
Failure to Provide Prescribed Therapeutic Diets and Follow Approved Menu
Penalty
Summary
Surveyors identified that the facility failed to provide prescribed therapeutic diets and did not follow the approved menu for residents requiring specialized diets. Specifically, one resident on a mechanical soft diet was observed receiving roast beef cut into pieces or chunks approximately 0.5 inches in size, rather than the ground meat specified in the facility's menu spreadsheet. Additionally, this resident was served diced or chopped chicken instead of ground meat, as required. The Certified Dietary Manager (CDM) and Speech Language Pathologist (SLP) both confirmed that the menu breakdown called for ground meats, but the facility did not offer ground diets, instead providing bite-sized or chopped meats for mechanical soft diets. Another resident with diagnoses including Type 2 diabetes and chronic kidney disease was prescribed a carbohydrate-controlled, high-protein diet with regular texture and thin consistency. Observations revealed that this resident received meals inconsistent with the prescribed diet, such as two slices of wheat bread and two strips of bacon for breakfast, and two rolls for lunch instead of the specified breadstick and cauliflower. The CDM acknowledged that the resident received too much bread and bacon, and that bacon is not permitted on the CKD5 diet. The CDM also stated that he substituted rolls for breadsticks due to unavailability and used a high-protein diet in place of the specific CKD5 diet, as the menu and electronic health record (EHR) did not match. Interviews with dietary staff, including the CDM, Dietetic Technician (DTR), and the facility's Dietitian, revealed a lack of alignment between the EHR diet orders and the food service supplier's menu spreadsheets. Staff admitted to not having reviewed the new menu breakdowns and to making substitutions or using alternative diets when the prescribed diet was not available or did not match the menu. The Dietitian confirmed that this mismatch had occurred previously and required customization, but there was no clear process to ensure residents consistently received the correct therapeutic diets as ordered by their physicians.
Plan Of Correction
Resident #1 prescribed therapeutic diet order was reviewed and updated per physician order. The Registered Dietician reviewed and updated the facility's menu to ensure a therapeutic diet is being provided for Resident #45 and Resident #1. A quality audit of current residents on a therapeutic diet was conducted to ensure the prescribed order is being followed, and to ensure the facility is following the menu for residents on a therapeutic diet. The Administrator educated the CDM (Certified Dietary Manager) on ensuring that prescribed therapeutic diet orders are being followed and ensuring the menu is being followed for residents on a therapeutic diet. The Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that prescribed therapeutic diet orders are being followed and that the menu is being followed for residents on a therapeutic diet. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Provide Therapeutic Diets as Prescribed
Penalty
Summary
The facility failed to provide therapeutic diets according to physician orders for two residents, leading to deficiencies in dietary services. Resident #1, who was admitted with medical diagnoses requiring a specific diet, did not receive the prescribed pureed texture and double portion protein/entrée at each meal. During an observation, Resident #1 was given a mechanical soft diet instead of the required pureed diet, and staff were unaware of the resident's dietary needs. The Dietary Manager was not informed of the diet change, resulting in the resident receiving incorrect meal portions. Resident #25 also did not receive the prescribed double portions of protein as indicated in the physician's orders. Despite the meal ticket specifying double portions, the resident received only one patty of Salisbury steak instead of two. The Registered Dietician confirmed that the resident should have received double portions due to previous weight loss and the need for increased nutritional intake. The facility's dietary staff failed to follow the meal ticket instructions, leading to the resident not receiving the necessary dietary support. The facility lacked a policy and procedure for following and honoring meal tickets and diets, contributing to the oversight in providing the correct meals to residents. The dietary staff, including the Cook and Dietary Aide, were unable to explain how the error occurred, indicating a lack of communication and oversight in the dietary service process. The absence of a structured protocol for ensuring dietary orders are followed resulted in residents not receiving the appropriate nutrition as prescribed by their physicians.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified resident #1: Resident was provided an additional serving of protein during lunch meal service per physician order. Diet orders were reviewed by the Chief Nursing Officer. Tray ticket updated with Puree diet per physician order and Speech recommendations. Resident did not suffer any adverse effects from not receiving the proper diet texture. Resident #1 was assessed by the APRN. APRN progress notes documented: CTA. No chills or increase in or No decrease in SPO2 noted. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review completed by Certified Dietary Manager/designee to ensure the residents receive meals per physician order, tray tickets match the physician order, and residents receive double portions/2x entrée. Quality review completed by the DON/designee r/t ensuring residents are provided with snacks when requested to be completed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Dietary staff re-educated by the Certified Dietary Manager on the components of this regulation and that residents receive meals per physician order, tray tickets match the physician order, tray line validates what is served match the tray ticket, and residents receive double portions/2x entrée. When the Dietary Manager is not present, the dietary staff will update the sheet located in the kitchen to document new admissions, re-admissions, or diet changes and update the pre-printed tickets with changes, write a ticket with new admissions/re-admissions for the Dietary Manager to input in the tray card system upon return to the center completed. Current Certified Nursing Assistants re-educated by the DON/designee r/t ensuring residents receive snacks upon request to be completed. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Certified Dietary Manager/designee to conduct ongoing quality monitoring through visual observation of the tray line and meal service in the dining room to ensure residents are provided meals per physician order 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, twice weekly x 4 weeks then weekly and PRN as indicated. DON/designee to conduct ongoing quality monitoring through resident interview and observation to ensure snacks are provided upon request 3 x weekly x 2 weeks, twice weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.
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