Failure to Implement Dietitian Recommendations and Provide Prescribed Supplements
Penalty
Summary
The facility failed to implement the dietitian's recommendations and ensure prescribed dietary supplements were provided to two residents experiencing weight loss. For one resident, weight records showed a downward trend over several months. The dietitian recommended double portions at breakfast and the addition of a house supplement twice daily to address the weight loss. However, these recommendations were not reflected in the resident's order summary or meal ticket, and there was no evidence that the double portions or supplement were provided. The dietitian confirmed she could not enter orders directly and relied on facility staff to implement her recommendations, which were not carried out. Another resident, who was on dialysis and had recently been hospitalized, experienced significant weight loss and was prescribed a Magic Cup supplement daily at lunch. Although the supplement was listed on the resident's meal card and the facility had it in stock, observation during a meal service showed the supplement was not provided with the resident's tray. Staff interviews confirmed the supplement should have been given, and the dietitian stated the order for the supplement was still active. The facility's weight monitoring policy requires interventions to maintain nutrition goals, but these were not implemented as required for the residents involved.