Failure to Follow Menu and Serve Correct Portion Sizes for Modified Diets
Penalty
Summary
The facility failed to follow the prepared menu and serve the correct portion sizes for residents on mechanical soft, ground meat, and pureed diets. Specifically, for a planned lunch meal, staff served mechanical soft BBQ chicken and pureed BBQ chicken using a #12 scoop (2.67 oz) instead of the required #10 scoop (3.2 oz) for mechanical soft and #8 scoop (4 oz) for pureed, as indicated on the facility's Spring Cycle Menus. This deviation affected 30 residents on mechanical soft or ground meat diets and 21 residents on pureed diets. The facility's policy required that menus be followed, and any deviations be recorded and archived, but this was not done in these instances. Interviews with dietary staff, the Dietary Director, the Registered Dietitian, the DON, and the Administrator confirmed that the expectation was to follow the menu and serve the correct portion sizes to ensure residents received adequate nutrition and the nutrients ordered by physicians. The staff member responsible for serving the meals acknowledged using the incorrect scoop sizes and confirmed the discrepancy after reviewing the menu. The deficiency was identified through observation, interview, and review of facility documents and policies.