Failure to Provide Physician-Ordered Diet to Resident
Penalty
Summary
The facility failed to ensure that a resident's meals were provided as ordered by the physician. A review of the medical record for a resident with multiple diagnoses, including Alzheimer's disease, protein calorie malnutrition, and dementia, showed a physician order for a fortified foods diet with regular texture and thin liquids, along with a house supplement three times daily. However, observation of a lunch meal revealed the resident received a mechanical soft diet with double portions of protein and fortified mashed potatoes, which did not match the physician's order. The resident's meal ticket and dietary manager both confirmed the mechanical soft diet, but there was no documentation of a physician order for this change in the medical record or nursing notes. Interviews with staff revealed confusion regarding the resident's current diet order. The MDS Coordinator confirmed the MDS did not reflect a mechanically altered diet, and an LPN admitted to changing the diet order in the electronic medical record without clear documentation of the source of the order. The Director of Nursing also confirmed the absence of documentation for the diet change. The facility was unable to provide a policy related to dietary orders, further highlighting the lack of proper documentation and communication regarding dietary changes for the resident.