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F0692
D

Failure to Provide Physician-Ordered Double Meal Portions for Resident with Failure to Thrive

Macomb, Illinois Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with diagnoses of Anorexia, Adult Failure to Thrive, and Protein-Calorie Malnutrition was not provided with physician-ordered double meal portions as required by their care plan and physician orders. The resident's dietary slip and physician order sheet both documented the need for double portions and cottage cheese with lunch and supper, with the option for additional helpings if needed. Despite these orders, observations showed that the resident consistently received only single portions at meals. The resident reported that dietary staff instructed him to wait until others were served before requesting a second portion, which often resulted in no additional food being available. Interviews with dietary staff confirmed that double portions were not routinely provided, and staff were unaware of the physician's order for double portions. The Director of Nursing acknowledged that the resident's dietary order required double portions to be served without the resident having to request them. These actions and inactions led to the resident not receiving the prescribed nutritional support necessary for his medical condition.

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