Failure to Serve Prescribed Small Portion Diets to Two Residents
Penalty
Summary
The facility failed to ensure that dietary staff served the correct meal portions to two residents who were prescribed small portion diets. For both residents, medical records and care plans indicated the need for small portions as part of their dietary orders, with one resident on a no added salt diet and the other on a regular diet with small portions requested. During a lunch meal observation, both residents received meal trays with the same portion sizes as other residents who did not have small portion orders. The diet cards for both residents clearly indicated the need for small or half portions, but the food served did not reflect these instructions. Interviews with the residents confirmed that they consistently received full portions despite their dietary orders, and one resident expressed distress over not losing weight as a result. Staff interviews revealed that the process for calling out portion sizes during meal service was not followed correctly, leading to the error. The Food and Nutrition Services director acknowledged that the expectation was for correct portions to be served and confirmed that the observed trays did not meet the prescribed dietary requirements. Facility policy and job descriptions also required adherence to portion control guidelines, which was not followed in these instances.