Failure to Follow Physician-Ordered Diets and Menu Portion Sizes
Penalty
Summary
The facility failed to ensure that planned menus and physician-ordered diets were followed for residents, resulting in discrepancies in portion sizes served. Specifically, one resident with an order for small portions received a full portion of protein, bread, side dish, and dessert, while another resident with an order for a double portion of protein received only a regular portion. These errors were confirmed through observation, interviews with staff, and review of meal tickets and order summaries. The Registered Dietitian verified that the residents did not receive their correct diet orders as prescribed. Additionally, during a lunch meal service, residents on a regular portion diet were served baked chicken portions that were smaller than the prescribed 3 ounces. Weighing of the chicken pieces revealed that the portions ranged from 1.3 to 2.6 ounces, which did not meet the menu requirements. The dietary staff acknowledged that the correct portion sizes were not served, and the Certified Dietary Manager was unable to explain why the ordered four-ounce boneless chicken pieces did not meet the required portion size after preparation. Interviews with dietary and nursing staff revealed a lack of clarity and consistency in the process for checking and verifying that residents received the correct diets. The Certified Dietary Manager and Director of Nursing both indicated that it was the responsibility of dietary and nursing staff to ensure accuracy, but there was uncertainty about whether trays were double-checked before distribution. Facility policies and job descriptions reviewed indicated that staff were expected to follow meal cards and menu spreadsheets to ensure proper diets were served, but these procedures were not consistently followed.