Failure to Provide Ordered Therapeutic Diet to Resident
Penalty
Summary
The facility failed to ensure that a therapeutic diet was provided as ordered for a resident with a diagnosis of a syndrome causing excessive appetite and overeating. The resident was prescribed a diabetic diet limited to 2,000 calories per day, with specific instructions to substitute fruit for dessert. However, review of dietary records and direct observation revealed that the resident's lunch tray included both a cherry tart dessert and a mixed fruit cup, and the resident consumed both items. The planned diabetic menu for the day also exceeded the prescribed caloric limit by 220 calories. Interviews with dietary and nursing staff confirmed that the resident should not have received the cherry tart and that only the fruit cup was appropriate for their diet. Staff acknowledged difficulties in redirecting the resident from requesting extra portions and confirmed that the dietary orders were not followed as prescribed. The resident reported routinely receiving both a dessert and fruit at lunch and expressed difficulty in losing weight, despite efforts to comply with dietary restrictions.