Failure to Provide Prescribed Fortified Foods and Meals to Residents with Nutritional Concerns
Penalty
Summary
The facility failed to provide adequate nutrition to residents with identified nutritional concerns, as evidenced by the lack of fortified foods and missed prescribed meals for three residents. For two residents who were underweight or at risk for malnutrition, meal tickets and care plans specified the need for fortified foods such as fortified cereal and potatoes with all meals. However, direct observations on multiple occasions revealed that these fortified foods were not included on their trays, despite clear dietary orders and documentation. Staff confirmed that the residents did not receive the required fortified foods, and photographic evidence supported these findings. One resident with a diagnosis of malnutrition and a low BMI experienced significant weight loss over a short period. This resident reported dissatisfaction with the quality and temperature of the food and specifically noted not receiving the prescribed meal (spaghetti with meat sauce), instead receiving only the meat sauce. The registered dietitian confirmed that the meal provided did not match the meal ticket or the resident's dietary order. The resident's care plan had been updated to address his risk for malnutrition, but the prescribed interventions were not consistently implemented. Another resident with a history of Alzheimer's disease, anorexia nervosa, and dysphagia was also observed not receiving fortified foods as ordered. This resident had experienced a notable weight loss over six months, and the care plan included specific interventions to provide fortified foods at each meal. Despite these orders, observations showed that the resident's trays did not include the required fortified items, and the meal tickets continued to indicate the need for fortified foods. These failures were acknowledged by facility management and the registered dietitian during interviews.