Failure to Timely Notify Medical Director of Dietician Recommendations
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards of practice by not notifying a resident's Medical Director of the Registered Dietician's recommendations in a timely manner. According to the facility's policy, dietician notes and recommendations are to be given to the Director of Nursing (DON) for nursing staff to send to the physician for review and follow-up. In this case, a resident with multiple complex diagnoses, including supraventricular tachycardia, chronic kidney disease, chronic obstructive pulmonary disease, cardiac pacemaker, aphasia following cerebrovascular disease, and chronic atrial fibrillation, was admitted and had specific tube feeding orders in place. On 02/18/2025, the Registered Dietician made recommendations to change the resident's tube feeding formula and add liquid protein supplements. These recommendations were faxed to the Medical Director's office the same day. However, there was no follow-up via telephone after the facility did not receive a response from the Medical Director. The facility did not receive any correspondence regarding the recommendations until 03/05/2025, after the resident had already passed away in the hospital. Interviews confirmed that the process for follow-up was not completed as required by facility policy.