Failure to Provide Physician-Ordered Fortified Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet order prescribed by a physician was followed for one resident who had an order for a fortified diet. During observation, the resident's meal tray card indicated a fortified diet, but the resident was served tea instead of milk and did not receive the required fortified foods. The resident expressed a preference for milk and concern about losing weight. Record review showed the resident had a diagnosis of mild protein-calorie malnutrition and specific orders for a regular pureed diet with thin liquids, a fortified diet, and scheduled health shakes and snacks. Interviews with staff revealed that the LVN could not confirm if the meal provided met the fortified diet requirements, and the RN was unaware of how dietary staff prepared the fortified diet. The registered dietitian stated that dietary staff were expected to follow physician's orders and facility policy, and confirmed the resident should have received the fortified diet as ordered. The facility's diet manual described the Special Nutrition Program as a fortified food program to meet increased nutritional needs, but this was not implemented for the resident as prescribed.