Failure to Implement and Document Physician-Ordered Nutritional Interventions
Penalty
Summary
The facility failed to implement physician-ordered nutritional interventions for two residents identified as being at nutritional risk. For one resident with a history of autoimmune gastritis, dysphagia, and significant weight loss, the care plan included a mechanically altered diet and a physician's order for a daily nutritional supplement with documentation of the amount consumed. However, records did not show that the amount of supplement consumed was documented as ordered. Additionally, a physician's order for a speech therapy consult related to weight management was not carried out, and there was no documentation of a referral or evaluation by speech therapy. Interviews with staff confirmed that the orders were not followed, and there was no system in place to flag new physician orders for follow-up. For another resident at risk for altered nutrition due to psychotropic medication use and recent weight loss, a similar physician's order for a daily nutritional supplement with documentation of intake was not followed. Medication and treatment administration records did not include the required documentation of supplement consumption. Staff interviews confirmed the lack of compliance with the physician's orders for both residents.