Failure to Provide Ordered Nutritional Supplements and Correct Portion Sizes
Penalty
Summary
The facility failed to provide a resident with ordered oral nutritional supplements and correct portion sizes during meals. The resident, admitted in 2016, had diagnoses including dysphagia, speech and language deficits following cerebral infarction, and dementia, and was care planned for a mechanically altered diet with supplements as ordered. The resident’s MDS indicated severely impaired cognitive skills for daily decision-making, no significant weight loss, and receipt of a mechanically altered diet. Active orders included a regular diet with pureed texture and thin liquids, daily ice cream with dinner for weight stability, an eight-ounce high protein oral nutritional supplement with lunch, and an oral nutritional supplement twice daily with breakfast and dinner for weight stability. During observation of the lunch meal on 01/12/26, the resident was served a pureed meal with an oral nutritional supplement, but not the ordered eight-ounce high protein oral nutritional supplement. During the dinner meal the same day, the resident received a pureed diet with ice cream, but no oral nutritional supplement was present on the tray. On 01/13/26 at lunch, a staff member plating the meal used a green #12 (2.67 oz) scoop for pureed salmon and pureed collard greens and a 2-oz serving spoon for pureed chicken. The staff member stated she determined portions from the production sheet and confirmed she had used a 2-oz spoon for the chicken and #12 scoops for the salmon and collard greens. After reviewing the production sheet, she acknowledged that she should have served 4 oz of pureed chicken, 4 oz of pureed salmon, and 1/2 cup of pureed collard greens, and that the scoops used were not the correct portion sizes. The Dietary Director confirmed the #12 scoop was slightly over a 2-oz portion. In interviews, nursing, dietary, and administrative staff stated that dietary staff were responsible for placing supplements on trays, that kitchen staff were expected to follow the menu and portion sizes so residents received nutritionally sound meals, and that ordered oral nutritional supplements should be provided as ordered for residents’ nutrition and weight management. The facility’s Food and Nutrition Services policy required that each resident be provided a diet that meets daily nutritional and special dietary needs and that food and nutrition services staff inspect food trays to ensure the correct meal is provided to each resident.
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