Failure to Provide Double Protein Portions as Ordered
Penalty
Summary
The facility failed to follow a physician's order to provide double protein portions for a resident with diagnoses including heart failure and both acute and chronic respiratory failure with hypoxia. Despite a physician's order dated 2/21/25 and revised on 4/21/25 for double protein portions, observations on 05/05/25 and 05/07/25 showed that the resident received meal portions consistent with other residents, not the prescribed double protein. The resident's weight records indicated a decline from 222.0 pounds to 210.2 pounds over several months. The registered dietitian confirmed that the intervention for double protein portions was implemented in response to observed weight loss and that the expectation was for the order to be followed, but it was not adhered to during the observed meals. These findings were based on direct observation, record review, and staff interview, demonstrating a failure to provide adequate nutrition as ordered for the resident.
Plan Of Correction
F692 – Nutrition/Hydration Status Maintenance Element #1: R20's diet orders and care plan were reviewed and modified as needed. R20 was assessed by the Director of Nursing and/or designee to ensure no lasting effects from missing double portions. Element #2: The RD and/or designee conducted an audit of community residents with orders for double protein portions to ensure care plans and interventions are accurate per resident current status. Element #3: The Administrator reviewed the policy on Nutrition and Hydration and revised as necessary. Community staff were provided education on following orders, and verification of information on tray tickets to ensure residents receive meals as ordered. Element #4: The RD and/or designee will review 10 residents weekly for 12 weeks to ensure meals are delivered in accordance with the orders and preferences indicated on their tray ticket. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025