Failure to Follow Physician-Ordered Menu Portion Sizes
Penalty
Summary
The facility failed to follow the approved menu and physician-ordered dietary requirements for multiple residents during meal service. Specifically, seven residents with physician orders for large or double portions were served only a single portion of chili, despite the menu specifying a double portion. Observations of the lunch service revealed that cooks used a single 6-ounce ladle for all residents, and no double portions were prepared or served. Staff interviews confirmed that all residents received the same portion size, and the dietary manager was unaware that double portions had not been provided as ordered. Additionally, seven residents on a pureed diet received only 4 ounces of chili instead of the 6 ounces specified on the menu. Twelve residents with orders for a regular or mechanical soft, low concentrated sweets (LCS) diet received a full slice of cake rather than the half slice indicated on the menu. Dietary staff confirmed that all residents received the same size dessert portion, and the dietary manager was not aware of the need to provide a half slice for those on an LCS diet. These failures were identified through direct observation, record review, and staff interviews, affecting a total of 26 residents.