FOOD TEMPERATURES Foods will be maintained at proper temperature to insure food safety. 1. The point of service temperature to residents will be within the range of 120-140 degrees based on the resident's preference. 2. The temperature of potentially hazardous cold foods will be not greater than 40 degrees F during tray assembly and 45 degrees F when served to the resident. 3. The cook is responsible to see that all food is at the proper temperature. 4. The temperature will be taken and recorded for all items at all meals. Record temperatures on extended menus. 5. Test trays will be made up periodically and the temperatures, as to be served to the resident, will be recorded by the Dietary Manager. 6. The following range of temperatures is recommended for food at point of tray assembly. a. Broth, soup, hot beverages 180-190 degrees F b. Meat, portioned for service 160 degrees F c. Casserole dishes, creamed 160 degrees F items, creamed soups d. Potatoes and vegetables 160 degrees F e. Chilled food and beverages 40 degrees F or below 7. Heating food in the steam table is prohibited. Heating food to the proper temperature is accomplished by direct heat (stove, oven, steamer, etc.) and food is then transferred to the steam table not more than 30 minutes before meal service.
RESIDENT FOOD REFUSAL Reasonable efforts shall be made to substitute nutritional equivalents for foods refused by residents. 1. Nursing is to notify Dietary Manager or designee when residents refuse food. 2. The Dietary Department will offer food of equal nutritional value. A choice of available foods will be offered (cottage cheese, milk, juice, fruit, cereal, etc.) 3. If meal refusal or poor food consumption continues to be a problem, weekly weights are to be initiated and the physician contacted. If a five percent weight loss is incurred the physician is to be contacted. If an insulin dependent diabetic continues to eat poorly or refuses meals, the physician is to be contacted by the nursing staff.
RESIDENT S RIGHTS: REFUSAL OF DIET The resident shall have the right to refuse his/her prescribed diet, provided that the following procedures are followed. 1. When a resident indicates that he/she no longer wishes to follow the diet prescribed by the physician, the resident s physician will be notified. The Director of Nursing, the Dietary Manager, and, if possible, the Consultant Dietitian will also be made aware of the resident s request. 2. The Consultant Dietitian, Dietary Manager and Director of Nursing will discuss with the resident the possible and probable consequences of failure to follow the diet as prescribed. The content of this discussion will be documented in the resident s medical record. 3. The resident will sign this documentation in his/her medical record, stating that the consequences of failure to follow the diet have been explained to him/her. If the resident cannot write, two witnesses will sign the record. 4. The resident s guardian, representative, or family member will be notified of the resident s decision. The Social Service Director shall also be notified if there are no responsible persons as stated above. 5. Once the above procedures have been followed, the facility and its employees shall be immune from liability for consequences of failure to follow the diet prescribed by the physician. 6. After steps above have been taken, the resident shall be served the diet as desired. APPROVED: Resident: Date: Witness: Date: Witness: Date:
CARBOHYDRATE REPLACEMENT FOR THE DIABETIC If Diabetic Refuses: Offer Any Of The Following: 1 c skim milk 6 saltines or 3 graham crackers 1 serving starch/vegetable ½ c apple or orange juice or 1 c buttermilk or milk 1 roll, 2 cornbread ½ c sherbet** biscuit, slice of bread or ½ c ice cream** 1 serving fruit or juice ½ c carbonated drink** ------------------------------------------------------------------------------------------------------------ meat, cheese, fish, poultry poultry, egg, or meat subst. meat alternate from dietary ------------------------------------------------------------------------------------------------------------ margarine, mayonnaise, bacon, salad dressing no substitute ----------------------------------------------------------------------------------------------------------- **Only if nausea or vomiting is present. Request a full or clear liquid diet. EXAMPLE: If resident refuses ½ biscuit and 4 oz orange juice, give ½ c skim milk (for biscuit) and 3 graham crackers (for orange juice).
MENU ALTERNATES An alternate meat or entrée, an alternate vegetable, and alternate starch should be provided at every meal in the event of personal food preferences or refusals. Alternative food must be approved by the Dietary Manager. 1. In addition to the menu items, an alternate meat or entrée, alternate starch and alternate vegetable should be prepared by the cook for the meals prepared as needed. 2. In addition, the following foods will always be available to the residents in the event they refuse the scheduled alternate: a. Soup b. Cheese c. Cottage Cheese d. Peanut butter and jelly e. Eggs f. Vegetable juice 3. Foods will always be available for residents experiencing gastric upset. They include: a. Ginger Ale or lemon lime soda b. Gelatin c. Broth/soup d. Assorted juices e. Sherbet 4. The following Starchy Vegetables should not be used as a substitute for a green or yellow vegetable on the menu: Corn Black-eyed Peas Baked Beans Yams White Potato English Peas Lima Beans Butter Beans Sweet Potato Acorn Squash Rice
NOURISHMENTS Nourishments are provided in accordance with the prescribed diet. Individual and/or bulk nourishments are delivered to the nurse s station for consumption by residents whose diet orders are not restrictive. They are provided on a routine basis for resident preference or satiety. 1. Snacks and nourishments are provided at 10AM, 2PM, and 8PM. Between meal snacks and bedtime nourishments are offered to all residents unless contraindicated by physician. 2. The stock nourishment level is described below for each of these times. Dietary personnel deliver these nourishments to the nursing stations just before time for passing. 3. If individual requests are made for specific nourishments, the food item is labeled and dated with the resident s name before delivery to the station. DESCRIBE STOCK NOURSHMENT LEVEL
BETWEEN MEAL SNACK/BEDTIME NOURSHMENTS Between meal snacks and bedtime nourishments are to be offered to all residents unless contraindicated by the physician diet order. PROCEDURE 1. Between meal snacks may consist of juice beverages, Kool-Aid, punch, lemonade, tea, etc. Cookies or crackers may also be offered. The bedtime nourishment must consist of foods that are nourishing. These include milk, 100% juices, cookies, crackers, fruit, etc. 2. Dietary should develop a snack nourishment stock level for each of the nursing stations. This would consist of the specified number of juice pitchers, cartons of milk, cookies or crackers. Cookies and crackers may be placed in a covered and labeled storage container and delivered to the nurse stations. Nurses should use clean tongs to pass these items when necessary. 3. Snacks/Nourishments are usually delivered a AM PM hs to the nurse stations. Nursing should be responsible for placing those items needing refrigeration in the pantry refrigerator at the station. 4. Physician ordered snacks and nourishments such as skim milk and graham crackers for diabetics, sandwiches ordered by the physician, or supplements ordered by the physician are to be labeled and dated with the residents name, room number, and date before delivery to the station. 5. Physician ordered snack and nourishments are to be written on a nourishment list and posted in dietary for employees to follow when preparing these items daily. This list needs to be updated regularly. This list should also be posed at the nursing stations. 6. It is important that the stock nourishment level be reviewed frequently so that adequate snacks/nourishments are supplied and controlled well. 7. According to regulation, nursing is to pass snacks and nourishments from room to room. It is not acceptable to announce that snacks are being served from the nursing station. 8. Dietary should check the pantry refrigerators every morning to see that snacks are being passed. Those items that have not been passed should be returned to the kitchen for the Dietary Manager to follow up on. Outdated cartons of milk should be removed on a daily basis by Dietary, Pitchers of juice over 48 hours old should be returned to dietary, sanitized, and refilled for the stations.
SUPPLEMENTS Supplements will be provided to offer therapeutic nutritional support. A physician s order will be required. 1. Residents receiving supplements may include those who are underweight, who are on therapeutic diets and those with poor intake (50%), weight loss, skin problems, and other problems addressed on care plans. 2. A supplement list is maintained for residents receiving physician ordered supplements and calorie-controlled diets 3. This list is posted in Dietary and at each nursing station. 4. These supplements are delivered by dietary in individual portions which are labeled with resident s name, date, and time. 5. Consumption of these supplements is recorded in the resident s medical record by nursing services. Recommended milkshake supplement for use is the 6 oz mighty shake with the following breakdowns: 280 calories 9 gms protein 6 gms fat 48 gms carbohydrate
SERVICE OF FOOD DURING ACTIVITIES Food shall be provided by the Dietary Department upon request of the Activities Department for food related activities. PROCEDURE 1. Therapeutic diets must be considered when food is served during activities. 2. The Activities Director will be made aware of residents diets by the Dietary Manager. Snacks can then be planned accordingly. When groups bring snacks in for activities, it may be suggested that they include items allowed such as artificially sweetened punch, etc. 3. Residents on calorie-controlled and diabetic diets may receive a bread exchange at an activity and have this amount deducted from their next meal. This information must be communicated to the Dietary Department in each instance.
RESIDENT COUNCIL MEETINGS Comments, positive or negative, will be channeled through the Dietary Department from the Resident s and Family Council PROCEDURE 1. The Dietary manager will attend the Resident s Council meeting upon invitation, for the purpose of improving dietary services. 2. Input will be solicited from the residents and families regarding dietary services. 3. In addition, before menu revisions are scheduled, questionnaires may be distributed to residents regarding menu preferences.
MEAL HOURS Meals are served at regularly scheduled hours. Between meal and bedtime snacks are offered and served at regularly scheduled hours and in accordance with prescribed diets. Dietary employee meal hours are scheduled by the Dietary Manager and do not conflict with meal service to residents. There must not be over 14 hours between dinner and breakfast the following morning. 1. The Dietary Manager will coordinate with department heads to establish employee meal hours that do not conflict with resident meal service. 2. The Dietary Manager is responsible for seeing that the established meal hour deadlines are met. This will assist Nursing Services in meeting daily residents care needs. 3. RESIDENT MEAL HOURS: Breakfast Lunch Dinner 4. EMPLOYEE MEAL HOURS: Breakfast Lunch Dinner 5. Add any additional meal hours here if not adequate room in number 3, or number 4.
DIETARY TRAY CARDS Each resident shall have a diet tray card. The diet tray card must be neat, legible, and clean. The tray card must identify the following information. 1. Resident s name 2. Resident s room number 3. Resident s bed number 4. Resident s diet exactly as ordered by physician 5. Resident s beverage preference 6. Resident s food preference 7. Resident s food dislikes and allergies 8. Location of meal The resident s tray card will agree at all times with the clinical chart and diet order. 1. A diet tray card will be used for each resident receiving a meal from the Dietary Department. The card shall contain the information as stated above. 2. Cards should be examined after each meal and wiped clean. They are to remain clean, legible, and free of soil, stains and smears. Clean tray cards with very mild soap solution and clear water rinse. DO NOT RUN THROUGH DISH MACHINE. 3. Tray cards will be color coded to indicate special diets. Specific diet orders are to be written on the card. DIET Regular Soft/Bland No Added Salt Low Cholesterol/Low Fat Pureed Renal Mechanical Soft No Concentrated Sweets DOT COLOR CODE
4. Diets permitting salt substitute with physicians order should be clearly indicated on the diet card. 5. A permanent ink pen is recommended for writing on the diet tray cards. 6. Nursing service must be instructed on how to handle the tray cards to ensure they stay clean and uncontaminated. 7. Tray card holders are to remain clean. These can be run through the dish machine.
RESPONSIBILITIES OF NURSING SERVICE AT MEAL TIMES The Nursing Department is responsible for distributing food trays to all residents in the facility. The Nursing Department is responsible for all water pitchers. PROCEDURE 1. It is the responsibility of the Nursing Service to decide whether residents are served in their rooms or in the dining room. This information is communicated in writing to the Dietary Department by the Nursing Department. 2. The Nursing Department is responsible for distributing food trays to resident rooms and in dining rooms. 3. The Nursing Department is responsible for preparing residents for meals and for assisting residents who are unable to feed themselves in resident s rooms and in the dining rooms. 4. is responsible for picking up food trays from resident rooms and in the dining room. 5. is responsible for returning the tray carts to the Dietary Department. 6. The Nursing Department is responsible fro periodically checking resident rooms for misplaced silverware and other utensils and for returning found items to the Dietary Department. 7. Trays will not be passed in the Dining Rooms until nursing staff is present. 8. Resident s water pitchers will be sanitized times weekly on. Nursing will deliver pitchers to Dietary at during the day and will pick up clean water pitchers at.
DIETARY PERCENTAGE CHART The Dietary Percentage Chart will be used by Nursing Services to calculate percent of meals consumed for every patient. The documentation and percent of total meals will be based on the following food groups: MILK MEAT CHEESE EGGS 50%, FRUITS VEGETABLES 25%, AND BREAD CEREAL DESSERT 25%. Use the following food groups and percents to calculate intake of meals. Nothing eaten or bites only (less than 25%) =0% All fruits/vegetables or bread/cereal/dessert =25% All milk/meat/cheese/eggs or both other groups combined =50% All milk/meat/cheese/eggs or one other group = 75% Consumption of all groups = 100% The chart was designed to approximate values. The shaded segments of the imaginary tray indicate percent consumed. Compare this chart with actual meal consumption to determine patient intake.
ADAPTIVE SELF-FEEDING DEVICES The use of adaptive self-help feeding devices is encourage when determined to be helpful to the resident and not contraindicated by the physician. 1. On evaluation of the specific resident s needs for adaptive self-help feeding devices by Nursing, Physical Therapist and or Occupational Therapist, a request will be submitted to Dietary for the specific device needed. 2. The training and supervision of the resident s use of the adaptive self-help feeding devices will be channeled as directed by the Occupational Therapist or Physical Therapist to the Nursing Department. Where as Occupational Therapist or Physical Therapist is not available, the training and supervision of the resident s use of adaptive self-help feeding devices will be under the direction of the Director of Nursing. 3. The Dietary Department will be responsible for sanitizing the utensils after each use and placing the devices on the resident s tray as needed. 4. The device will be returned to Dietary when no longer needed.
DINING ROOM Residents will be encouraged to eat in the Dining Room unless contraindicated by Physician or Nursing Services. PROCEDURE 1. Residents will be assisted to the dining room as needed by Nursing Services 2. Residents trays or meals are distributed by nursing. 3. At least one person from Nursing Services will be stationed in the dining room during meal service to assist residents with eating and to handle any emergency situation that might arise. 4. Dining room tables should be adequate in height so that wheelchairs can fit underneath them for more comfortable eating. 5. The dining room will be cleaned after each meal by. 6. The dining room tables and chairs will be cleaned after each meal by.
EMPLOYEE GUEST MEALS Employee/guest meals are made available in the facility and comply with the regular diet on the respective day s cycle menus. Advance notice is provided to the Dietary Department of all employee/guest meal needs. A meal sign-up sheet is used. Notification to Dietary must be made on this sheet by: am for dinner meal pm for supper meal The regular diet is served exactly as noted on the menu to all employees and guests. Meal charges are handled by the business office The meal sign up sheet follows.
MEAL SIGN UP SHEET DATE MENU
FOOD BROUGHT IN BY VISITORS Food brought in by visitors for residents will not be stored or served by the Dietary Department. If food is brought in, it must be approved by the Charge Nurse before it is given to the resident. Visitors are discouraged from bringing protein food. Special request to bring protein foods to residents shall require approval from Administrator or Dietary Manager. All perishable food in resident s rooms shall be in tightly closed containers, labeled and dated well.