Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were provided as ordered by the attending physician for three residents. One resident, who had an order for a double portion regular diet with thin liquids, reported not receiving the required double portion of food on multiple occasions, as confirmed by both his statements and direct observation of his meal tray. Another resident, with an order for a general diet with mechanical soft texture, thin liquids, and double portion protein, was observed receiving only a single portion of protein on his tray. Both residents' medical records confirmed the dietary orders, and staff interviews acknowledged the importance of following these orders. Additionally, a third resident with orders for a no added salt, pureed texture, nectar thick liquids, and a magic cup supplement was observed receiving thin liquid juice instead of the prescribed nectar thick consistency. The staff member who provided the tray was unsure of the liquid's consistency and later replaced it with thickened juice after the deficiency was noted. The DON confirmed that not following diet orders, such as providing thin liquids instead of thickened liquids, can compromise resident safety and is an example of not adhering to physician orders.