Failure to Provide Physician-Ordered Therapeutic Diets and Supplements
Penalty
Summary
The facility failed to follow physician diet orders for two residents with specific nutritional needs. One resident, admitted with diabetes and malnutrition, had a physician order for a mechanical soft diet with double portions as an intervention for weight loss. Despite this, observations during a lunch meal revealed the resident did not receive a double portion of beef as ordered. Staff interviews confirmed that the dietary aide responsible for checking meal trays overlooked providing the double portion, and the dietary manager and registered dietitian both stated that double portions were expected to be provided as ordered. Another resident, admitted with a history of stroke and at risk for weight fluctuation, had a physician order for a frozen nutritional supplement twice daily. Observations on two consecutive days showed that the resident did not receive the ordered supplement with her lunch meal because the kitchen was out of the product. Staff interviews revealed that dietary staff did not notify nursing staff or the dietary manager about the unavailability of the supplement, and the registered dietitian confirmed that staff should have notified nursing so an appropriate substitute could be ordered. The administrator also stated that she expected residents to receive supplements as ordered and for nursing to be notified if they were unavailable.