Failure to Provide Physician-Ordered Fortified Foods and Monitor Nutritional Status
Penalty
Summary
The facility failed to provide physician-ordered fortified food diets to several residents and did not ensure proper monitoring of nutritional status for at least one resident. Specifically, three residents with orders for fortified foods did not consistently receive the prescribed fortified items at meals. Observations and tray ticket reviews showed that these residents were missing required fortified foods and supplements, such as super cereal, super mashed potatoes, super pudding, and additional beverages. Staff interviews confirmed that fortified foods were not being prepared or served prior to the survey, despite the necessary products being available in the facility. Additionally, one resident with significant weight loss and a history of dementia, muscle weakness, and lack of coordination was not properly monitored for nutritional intake. Documentation of meal intake and assistance provided was frequently missing for this resident across multiple months. There were also instances where the resident was coded as refusing or consuming no meals, yet there was no consistent follow-up or documentation to address these refusals. The resident's care plan required monitoring and assistance with meals, but these interventions were not reliably documented or implemented. Interviews with staff, including the Registered Dietitian and the Nursing Home Administrator, confirmed a lack of awareness regarding the failure to provide fortified foods and acknowledged the missing documentation for meal intake and assistance. The facility's own policies required physician orders for fortified diets and specified the components of the fortified food program, but these were not followed. The deficiencies were identified through clinical record reviews, resident and staff interviews, and direct meal observations.