Failure to Provide Diet as Ordered by Physician and Dietician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including failure to thrive, dysphagia, and major depressive disorder did not receive a diet in accordance with physician orders and dietician recommendations. The resident, who was cognitively intact, had an active physician order for a general diet with pureed texture, thin liquids, super cereal at breakfast, whole milk with meals, ice cream at lunch and dinner, and pudding with meals. However, during a meal observation, the resident was served a mechanical soft diet with chicken, mashed potatoes, fruit, and lemonade, and did not receive the required whole milk, ice cream, or pudding. The dietary slip accompanying the tray listed a regular diet with mechanical soft texture and did not reflect the current physician-ordered diet or supplements. Interviews with facility staff, including a CNA, LPN, Dietary Manager, Registered Dietician, and DON, confirmed that the meal ticket and tray did not match the resident's current dietary orders. The Dietary Manager and DON acknowledged that the tray should have included the specified supplements and that the facility should be following the active physician orders. The facility's policy requires compliance with physician diet orders and coordination between nursing and dietary staff, but this process was not followed, resulting in the resident not receiving the prescribed diet.