Failure to Follow Physician-Ordered Fortified Diet for Resident
Penalty
Summary
Staff failed to follow a physician-ordered therapeutic fortified diet for one of six sampled residents on such diets. Specifically, the dietary manager was observed plating food for a resident requiring a fortified diet but did not add any fortification to the main entrée, instead placing an extra pat of margarine on the tray. The margarine, intended as the fortification, was not incorporated into the food but left on the tray alongside the napkin. When the tray was presented to the resident, the certified nursing assistant did not offer the margarine and was unaware it was part of the fortified diet order. Another CNA also did not know that the butter pat was intended as fortification, stating that residents could eat whatever they wanted. The Director of Nursing confirmed that nursing staff were not aware of the role of the butter pat in the therapeutic diet and had not received training to ensure its use for residents requiring fortified diets. The registered dietitian stated that her expectation was for additional calories to be incorporated into the recipes, not simply presented as margarine pats on the tray. Facility policy required that individuals needing supplemental nutrition be served a suitable high calorie/high protein diet, with nursing staff supervising delivery and consumption of supplements and recording this in the medical record. These steps were not followed for the resident in question.