| 22 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2019-07-11 |
692 |
D |
0 |
1 |
01HJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the dietary department failed to offer a carbohydrate controlled therapeutic diet ordered by a physician at meal times for 2 (#s 91 and 328) of 42 sampled residents. Findings include: 1. During an observation on 7/8/19 at 5:26 p.m., resident #91 received a full portion, filled to the brim of the bowl, of turkey and dumplings with peas and carrots. Resident #91 also received a salad, and a Diet Coke for dinner. During an interview on 7/8/19 at 5:28 p.m., staff member W stated a resident on a carbohydrate controlled diet should have been served no dessert, less potatoes, diet soda, and given less food or a half portion. During an interview on 7/9/19 at 1:54 p.m., staff member Y stated that all specialized diets should have been captured on the therapeutic spreadsheets that showed which food should be provided for the meal per the menu, as well as portion sizes. The sheets should have been used as a reference during meals. Carbohydrate controlled diets should have been provided unless the resident refuses. Staff member Y stated resident #91 should have received the baked turkey breast for dinner and not the turkey and dumplings. During an observation on 7/9/19 at 8:15 a.m., resident #91 received an omelet and muffin. Review of the Specialized Diet Spreadsheet for 7/9/19 showed a resident on a carbohydrate controlled diet should have received a Denver omelet, fresh fruit, yogurt, and cold cereal. Review of the Week 5 Monday Specialized Diet Spreadsheet, for 7/8/19, showed the carbohydrate controlled diet choices were pork chop smothered, creamy mushroom rice, and chocolate pudding, or baked turkey breast, peas, carrots, and onions. No baked turkey breast was observed during the meal. Review of resident #91's diet card showed, carb controlled diet was marked. The rest of the card was blank. Review of resident #91's diet order showed carbohydrate controlled diet. Review of resident #91's blood sugars showed 37 blood sugars over 200 and three blood sugars not marked as high with a reference range of 68-110 from 6/10/19 to 7/3/19. 2. During an observation on 7/9/19 at 12:12 p.m., staff member W was serving lunch with the specialized diet spreadsheet book not visible and it was on the counter in the pantry. Resident #328 was served carrot salad, mashed potatoes and gravy, a hot turkey sandwich smothered in gravy, and a cookie for dessert. During an interview on 7/9/19 at 2:24 p.m., staff member X stated that the chef and CNA are responsible for making sure the residents receive the right diets by following the diet cards. Staff member X stated the expectation is that the chef is to follow the spreadsheets for diets. Staff member X stated that the meal cards that the CNA follows are pretty clear and capture what should and should not be served. Staff member X stated that she was not sure how specialized diets are monitored or how they prevent the wrong diets from being served. During an interview on 7/10/19 at 9:57 a.m., staff member AA and staff member Z stated that diet spreadsheets are given to the cooks for the day and should be utilized while serving. Staff member AA stated that a medical diet is a physician order [REDACTED]. During an interview on 7/10/19 at 10:35 a.m., staff member J stated specialized diet cards are orange (colored), for carb control. Staff member J stated responsibiity for going around and taking food orders for the day to see which of the two options on the menu the resident would prefer. Staff member J stated he had never seen nor been trained on the specialized diet spreadsheet menu. Staff member J stated, It would be helpful to know what is in the diet. During an interview on 7/10/19 at 10:39 a.m., staff member BB stated he had not been trained on specialized diets. Staff member BB was responsible for serving meals and providing diet cards to the chef. Review of the Week 5 Tuesday Specialized Diet Spreadsheet showed for lunch a resident on a carbohydrate control diet should have received a hot turkey sandwich, poultry gravy, carrot salad, and fruit. Review of resident #328's diet card showed was marked carb control under diet the sectional, and the rest of the card was blank. Review of resident #328's diet order showed the resident was on a carbohydrate controlled diet. |
2020-09-01 |