Failure to Implement Dietician's Order for Nutritional Intervention
Penalty
Summary
A resident with diagnoses including severe protein-calorie malnutrition, chronic kidney disease, depression, and repeated falls experienced significant weight loss over several months. The resident's care plan identified a nutritional problem and set goals for weight maintenance or gain, with interventions to provide diet as ordered. The registered dietician (RD) recommended offering ice cream three times daily between meals to increase calorie intake, as the resident declined other supplements but agreed to eat ice cream. However, this recommendation was not transcribed into a physician's order or added to the medication administration record (MAR), and staff were unaware of the need to provide ice cream. Multiple interviews with the resident, nursing staff, and dietary staff confirmed that the resident had not received the recommended ice cream, and there was no order in place for it. The assistant director of nursing (ADON) and director of nursing (DON) were unaware of the process for implementing RD recommendations, and the RD stated he had communicated the recommendation via email but expected it to be implemented promptly. Facility policy requires dietary supplement orders to specify type, amount, and frequency, and to be maintained in the clinical record, but this was not followed, resulting in the resident not receiving the prescribed nutritional intervention.