Failure to Implement Dietitian's Recommendations for Nutritional Supplementation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following the Registered Dietitian's (RD) recommendations. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, dysphagia, dementia, and depression, experienced weight loss over a period of time. The care plan included monitoring for signs of dysphagia and providing supplements as ordered. The physician's orders specified a regular diet with pureed texture, nectar thickened liquids, and large portion protein per meal. The RD recommended providing a magic cup supplement daily at lunch due to the resident's weight loss and variable oral intake. Despite these recommendations, the facility did not provide the recommended magic cup supplement to the resident. The Director of Nursing (DON) confirmed that the RD's recommendation was not implemented and acknowledged that this could lead to further weight loss. The facility's policy required evaluation and intervention for undesirable weight changes, including ensuring adequate calorie and protein intake, but this was not followed in this case.