Failure to Provide Ordered Therapeutic Diets to Residents
Penalty
Summary
Two residents were not provided with the therapeutic diets ordered for their medical conditions. One resident with type 1 diabetes, who was on a carbohydrate-controlled diet, consistently received high-carbohydrate meals and was not offered low-carbohydrate options as requested by the resident and family. The resident experienced high blood glucose readings, and the family expressed concern that insulin was administered without regard to the carbohydrate content of meals. Observations confirmed that the resident was served meals inconsistent with the prescribed diet, such as being given bread pudding instead of fruit, and the dietary manager was unable to specify the carbohydrate content of meals provided. Another resident, with end stage renal disease, diabetes, and gastroparesis, reported not receiving a renal diet as ordered by the physician. The resident stated that meals included high-potassium foods such as beans and bananas, which are not appropriate for a renal diet. The resident had communicated these concerns to dietary staff without resolution. Review of dietary records and interviews with the dietary manager and registered dietitian revealed a lack of awareness and oversight regarding the specific dietary needs and preferences of these residents, and the computer system used for meal planning did not consistently ensure compliance with therapeutic diet orders.