Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that two residents received diets as ordered by their physicians. For one resident, a review of the medical record and direct observation revealed that the lunch tray did not include soup, despite a physician's order specifying a fortified, pureed diet with soup at lunch and dinner. Both a CNA and an LVN confirmed that the soup was missing from the tray, and the resident's orders were not followed as written. For another resident, who was at risk for aspiration and excessive weight loss due to dysphagia, the lunch tray included soup that was not pureed, contrary to the physician's order for a pureed, honey-thick consistency diet. Additionally, the tray did not include the required extra entree. Staff interviews and medical record reviews confirmed that the resident should have received all items in pureed form and a double portion of the entree, as ordered. The DON stated that licensed nurses were responsible for checking trays to ensure compliance with diet orders, but this process failed to prevent the deficiencies.