Failure to Provide Prescribed Diet to Resident with Diabetes
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including type 2 diabetes mellitus, anemia, vitamin D deficiency, muscle weakness, abnormal gait, and left-sided hemiplegia and hemiparesis, was not provided with a fortified consistent carbohydrate (CCHO) diet as ordered by the physician. The resident's dietary order specified a regular texture, regular liquid consistency, and double portion protein for breakfast and dinner for weight and nutritional management. During a facility tour, the resident's breakfast tray was found on another resident's bedside table, and the resident reported not recalling having breakfast or being aware that the tray was placed there. No staff were present in the room at the time of observation. Interviews with facility staff revealed a lack of awareness regarding whether the resident had received breakfast, and no explanation was provided for why the tray was misplaced. The facility's policies required proper identification and verification of meal trays to ensure residents received the correct diet, as well as timely meal service. However, these procedures were not followed, resulting in the resident not receiving the prescribed meal in accordance with their dietary needs and physician's orders.