Failure to Provide Physician-Ordered Therapeutic Diet Supplement
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cerebral infarction, dysphagia, and depression, and who was assessed as having severely impaired cognition and requiring moderate assistance with activities of daily living, did not receive a physician-ordered therapeutic diet supplement. The resident was prescribed a fortified pureed diet with honey thick liquids and Magic Cup twice daily as a supplement, as documented in the order summary and medication administration record. On the observed date, the resident's lunch tray, which was supposed to include Magic Cup according to the meal ticket, was missing the supplement. This was confirmed by a certified nurse assistant during meal assistance. The dietary supervisor acknowledged awareness of the omission and stated that both the dietary aide and the nurse responsible for tray checks should have ensured the supplement was provided. The director of nursing confirmed that trays are checked by both dietary and nursing staff against diet orders. The facility's policy requires that food trays be inspected to ensure correct meals are provided to each resident.