Failure to Provide Prescribed Therapeutic Diet for Resident with Gastroparesis
Penalty
Summary
The facility failed to follow a prescribed therapeutic diet of small, portioned meals for a resident diagnosed with gastroparesis and Type I diabetes mellitus. The resident's care plan and electronic health record (EHR) included clear instructions for small, frequent meals—specifically, 4-5 small meals per day and a small particle diet. Despite these orders, multiple observations showed the resident consistently received regular-sized meal portions, and staff interviews confirmed that the resident was not provided with the prescribed small portions. The dietary manager also confirmed that the meal slip did not indicate the need for small-portioned meals, and the kitchen provided regular servings. The resident experienced a significant weight loss of more than five percent within one month, as documented in the EHR. Staff, including a registered dietician and the director of nursing, acknowledged that the resident should have been receiving small, frequent meals in accordance with their care plan and medical needs. The failure to provide the prescribed therapeutic diet was confirmed through observation, record review, and staff interviews, with no evidence that the dietary orders were being followed.