Failure to Follow Physician-Ordered No Added Salt Diet
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered No Added Salt (NAS) diet was served a packet of iodized salt with her lunch meal. The resident, who had a history of multiple fractures, chronic kidney disease, and hypertension, was admitted in February 2025 and had a care plan and physician's order specifying the NAS diet. Despite these orders, the resident received a salt packet on her meal tray, which she did not request. Observations and interviews confirmed that the meal ticket indicated the NAS diet, and both the Certified Nurse Assistant and Registered Dietician acknowledged that the resident should not have received extra salt. The Registered Dietician stated that nursing staff are expected to check meal trays before serving them to residents, and the Director of Nursing confirmed that prescribed diets should be followed. Facility policies also required that therapeutic diets be provided as ordered by the physician.