Failure to Provide Prescribed Diet to Resident
Penalty
Summary
The facility failed to provide food items consistent with the prescribed diet order for Resident R4. The physician's orders for Resident R4, dated 11/18/24, specified a Low Lactose diet, Mechanical Soft Ground Meat texture, and Nectar/Mildly Thick liquids. However, during dining observations on 1/7/24, at 12:15 p.m., Resident R4 was served turkey vegetable soup and had her liquids in a sippy cup, despite having no orders for adaptive equipment. The Dietary Director, Employee E9, confirmed these findings. Additionally, the Director of Nursing (DON) confirmed on 11/8/24, at 2:00 p.m., that Resident R4 should not have been served the soup or the sippy cup.
Plan Of Correction
Resident R4 was not affected by the deficient practice of not providing items consistent with their prescribed diet as the issue was discovered and addressed before the soup was served. There was also no negative effect for resident R4 who did not have orders for the two handle cup adaptive equipment. The Dietician/designee or the Director of Nursing/designee will audit orders for residents with specialty diets and/or adaptive dining equipment to ensure the appropriate orders are in place. The Dining Services Director/designee will educate team members on ensuring residents receive food/diet items as prescribed by physician orders by DON/designee. The Director of Nursing, Dining Services manager, dietician or designee will conduct observation audits at least five times weekly for 4 weeks on residents who are on modified diets to ensure team members are following the MD order. The audits will be completed and presented to the QAPI committee for further review and follow up if there are any negative trends identified.