Failure to Provide Prescribed Diets and Nutritional Supplements
Penalty
Summary
The facility failed to follow prescribed therapeutic diet orders and did not provide required nutritional supplements for two of four residents reviewed for nutritional supplements. For one resident with multiple diagnoses including psychosis, heart disease, and vitamin D deficiency, the facility did not provide the ordered double entree portions and peanut butter and jelly sandwiches as specified in the resident's diet order. Observations showed that the resident's meal tray was missing items listed on the tray ticket, and staff interviews revealed miscommunication and lack of proper documentation transfer between dietary and nursing departments. The dietary manager was unaware of the special diet order due to missing communication and did not check the electronic records, resulting in the resident not receiving the correct diet as ordered. Another resident with diagnoses including adult failure to thrive, depression, and chronic obstructive pulmonary disease did not consistently receive the ordered nutritional supplement (Ensure or Medpass 120 ml twice daily). The resident reported only receiving the supplement three times in a month, despite an active order for twice daily administration. Review of the medication administration record (MAR) confirmed multiple instances where the supplement was documented as unavailable. Staff interviews indicated that there had been issues with supplement availability, improper distribution to residents not on the supplement program, and a lack of communication to ensure the correct residents received their prescribed supplements. Both residents had care plans and active orders specifying the need for specialized diets and supplements to maintain their nutritional status. However, failures in communication, documentation, and supply management led to the residents not receiving their prescribed diets and supplements as ordered by their physicians. Staff, including the dietitian and DON, were not aware of the deficiencies until brought to their attention during the survey.