Failure to Provide Correct Meal Portion Sizes for Resident on Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure correct portion sizes for meals as required by dietary guidelines. During observation of a lunch meal service, a resident with Alzheimer's disease, chronic kidney disease, epilepsy, and severe cognitive impairment, who was on a mechanically altered diet due to dysphagia, was served a pureed meal with portions significantly smaller than those specified on the dietary spreadsheet. The meal included less than two ounces each of pureed pasta and vegetables, despite the dietary spreadsheet indicating larger portions were required. Serving utensils used did not match the required portion sizes, and a spoon with no measured serving size was used for one of the items. Staff interviews revealed that the dietary aide responsible for serving the meal was unaware of the correct portion sizes and used randomly selected utensils, relying on estimation rather than following the dietary spreadsheet. The dietary manager confirmed that staff should have used color-coded serving utensils with specific serving sizes and followed the dietary spreadsheet, but this was not done during the observed meal service.