Failure to Provide Ordered Dietary Supplement
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident with severe cognitive impairment, multiple diagnoses including dementia, dysphagia, and feeding difficulties. The resident's care plan and dietary orders specified daily ice cream as a nutritional supplement, with fortified pudding and high-calorie liquid supplements also documented. Observations on two consecutive days showed that the resident was served meals without the ordered ice cream or a substitute supplement. The resident's meal card confirmed the requirement for a 4-ounce ice cream supplement, but this was not provided. Interviews with staff revealed that the facility had been out of the ice cream supplement for two days, and staff were unclear about what should be provided as a substitute. The dietary director acknowledged the shortage and stated that fortified pudding should have been given in place of ice cream, but this was not done. The resident's family, present during meals, also noted the absence of the supplement. The administrator confirmed that staff are expected to follow therapeutic diet orders.