Failure to Implement Dietitian's Dietary Recommendations for Resident
Penalty
Summary
The facility failed to implement the Registered Dietitian's (RD) recommendations for a resident with brain cancer who was experiencing weight loss and had a low albumin level. The RD had assessed the resident and recommended discontinuing protein shakes, which the resident found too sweet and refused, and substituting them with a frozen supplement (Magic Cup) and adding peanut butter to all meals. The RD also recommended updating the resident's nighttime snack to a preferred tuna sandwich. These recommendations were documented and communicated to the Dietary Services Supervisor (DSS) via email, with the expectation that changes would be implemented within three days, as per facility policy. Despite these recommendations, observations and interviews revealed that the resident continued to receive the unwanted protein shakes and did not receive the Magic Cup supplement in a timely manner. The DSS acknowledged receiving the RD's recommendations but admitted to not entering the changes into the dietary software promptly due to being busy. As a result, the resident's dietary preferences and nutritional needs were not met as recommended by the RD, and the facility exceeded its own policy timeframe for implementing dietary changes. The resident, who had moderately impaired cognition, repeatedly expressed dissatisfaction with the provided supplements and meals, stating a preference for the frozen supplement and disliking the protein shakes. Multiple observations confirmed that the resident continued to receive the unwanted items, and staff interviews corroborated the delay in updating the dietary plan. Facility policy required dietary recommendations to be implemented within three days, but this was not followed, resulting in the resident not receiving preferred and recommended foods and supplements.