Failure to Provide Double Protein Portions for Resident with Weight Loss
Penalty
Summary
A deficiency occurred when a resident with a history of significant weight loss and multiple medical conditions, including hemiplegia, aphasia, end-stage heart failure, chronic kidney disease, and metastatic prostate cancer, did not receive double portions of protein as ordered by the physician. The resident's diet order specified a general diet with mechanical soft texture, regular/thin consistency, and double proteins at each meal, along with super cereal at breakfast. Despite this, the resident consistently received only single portions of protein at meals, as confirmed by both the resident and direct observation during meal service. The diet card and dietary spreadsheet reflected only a single portion, and the dietary manager was unaware of the double protein order. Interviews revealed that the dietitian had recommended super cereal but was not involved in the double protein order, which originated from nursing and was documented in the physician order sheet. The regional director of operations confirmed that the facility lacked a policy or procedure for notifying dietary staff of diet order changes. The resident's care plan included interventions to provide diet and supplements as ordered, but these were not implemented, resulting in the resident not receiving the prescribed nutritional support despite ongoing weight loss and expressed requests for additional food.