Failure to Provide Prescribed Dietary Supplements and Meal Modifications
Penalty
Summary
The facility failed to provide prescribed dietary supplements and appropriate meal modifications for three residents identified as at risk for weight loss or with a history of weight loss. For one resident with severe cognitive impairment and a history of diabetes, peripheral vascular disease, and amputation, the care plan and physician orders required health shakes at lunch and supper, as well as extra butter, margarine, and sauces at all meals. However, during observation, this resident did not receive the ordered health shake, extra sauces, dressing, or butter/margarine with their meal. The registered dietitian and physician both confirmed that these supplements and modifications were expected to be provided as ordered to address weight loss. Another resident with dementia and poor dental condition was ordered a pureed diet with honey thick liquids, extra butter/margarine, extra sauces, and pudding with protein powder at lunch and supper. Observation revealed that the resident received a meal with improper texture (chunky instead of smooth puree) and was missing the required breadstick, sauce, butter/margarine, and pudding. A third resident with dementia and a history of traumatic brain injury was ordered a mechanical soft diet with extra butter/margarine, sauces, and pudding at supper. This resident received food in pieces too large and hard to chew, and did not receive the required dessert, butter/margarine, or sauce. The facility's policy requires monitoring and intervention for undesirable weight loss, including the use of supplements, but these interventions were not consistently implemented for the affected residents.