Failure to Provide Physician-Ordered Fortified Diet
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, Alzheimer's disease, dysphagia, and major depressive disorder, was not provided with food in accordance with the physician's prescribed fortified diet. The resident's care plan and physician's order specified a dysphagia Level 1 puree texture with thin consistency and a fortified diet to increase caloric intake. However, during multiple observations, staff assisting the resident with meals confirmed that the meal trays did not contain extra butter or other means of fortification, despite the meal ticket indicating a fortified diet was required. Interviews with certified nurse assistants and the facility cook revealed that the standard practice for a fortified diet was to include a packet of extra butter on the meal tray, but this was not done for the resident in question. The registered dietitian confirmed that the fortified diet was intended to add extra calories and expected diet orders to be followed. The director of nursing also stated that diet orders should be followed and acknowledged the risk of nutritional problems if residents do not receive enough calories. A review of the resident's weight records showed a consistent decline in weight over several months, with the resident losing 23 pounds from September to April. The facility's policy required that therapeutic diets be provided as prescribed by a physician, with dietary and nursing staff responsible for ensuring the appropriate nutritive content. Despite these policies and clear orders, the resident did not receive the prescribed fortified diet during the observed meals.
Plan Of Correction
Therapeutic Diet Prescribed by Physician How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #30 was provided a fortified meal on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of residents with fortified diet orders on 04/11/2025 to ensure those residents had the appropriate fortified meal provided. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: d) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct meal according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. b) Registered Dietician / designee completed an audit of residents with fortified diet orders on 04/11/2025 to ensure those residents had the appropriate fortified meal provided. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: d) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct meal according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025 F 808 F812 Food Procurement, Store/Prepare/Serve - Sanitary How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Opened and undated food items removed and thrown away on