Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A resident with diagnoses including Alzheimer's disease and oral phase dysphagia had a physician order for a pureed no added salt (NAS) diet with lemon ice at meals, following a speech therapy recommendation to use lemon ice to facilitate oral movement and swallowing. Despite this order, observations during two separate lunch meals revealed that the resident did not receive lemon ice on her meal tray, and the meal tray ticket did not include the lemon ice order. Interviews with facility staff, including an LPN and the Certified Dietary Manager (CDM), confirmed that the lemon ice was not provided as ordered and was not listed on the tray ticket, despite being part of the current physician orders. This failure resulted in the resident not receiving the prescribed therapeutic diet as required by the physician's order.