Failure to Provide Prescribed Therapeutic Diets and Fortified Foods
Penalty
Summary
The facility failed to ensure that two residents received therapeutic diets as prescribed by their attending physicians. For one resident, who had diagnoses including dementia, heart failure, dysphagia, and high blood pressure, the care plan required a mechanical soft diet without dairy and the provision of fortified foods and Ensure Clear at all meals. On the observed date, this resident did not receive fortified food, Ensure Clear, or water as indicated on her tray card. Staff interviews revealed that the cook did not add fortified ingredients to the mechanically soft meal and did not serve any fortified food for lunch. The CNA assisting the resident was unaware of what should have been fortified on the tray, and the dietary manager confirmed that the cook was responsible for ensuring the correct diet and supplements were provided. Another resident, with diagnoses including diabetes, anorexia, anemia, and a history of stroke, was also not provided with the required fortified foods during a lunch meal. The resident's care plan and meal ticket specified a regular diet with consistent carbohydrates, no added salt, and fortified foods at all meals, including a specific order for fortified mashed potatoes at lunch. Observation showed that the resident did not receive the fortified mashed potatoes as indicated. The cook stated she was unaware that the resident required fortified foods and did not prepare them. The dietary manager and DON both acknowledged that the resident should have received fortified foods as ordered, and the DON noted a typo on the meal ticket but confirmed the expectation for fortified foods to be provided. Facility policy required that all residents receive foods in the appropriate form and nutritive content as prescribed by the physician, with all diet orders communicated to the dietary department and validated by the dietary manager. Despite these policies, the failures in communication and execution led to residents not receiving their prescribed therapeutic diets and supplements as ordered.