Failure to Provide Therapeutic Diet as Recommended by IDT
Penalty
Summary
A deficiency occurred when the facility failed to provide a therapeutic diet as recommended by the Interdisciplinary Team (IDT) for a resident with a history of dysphagia, major depressive disorder, and gastro-esophageal reflux disease. The resident experienced significant weight loss over several months, as documented in the Weights and Vitals Summary, and was identified as high risk for excessive weight loss by the Registered Dietician. The IDT Weight Management Care Plan recommended the addition of a Glucerna shake once daily for one month to address the resident's nutritional needs. Despite this recommendation, the Assistant Director of Nursing (ADON) did not obtain a physician's order to resume the Glucerna supplement after the resident's readmission, resulting in the resident not receiving the supplement for five days. The Medication Administration Record still reflected a previous order, but the supplement was not administered due to the lack of a current physician's order. Both the ADON and the Director of Nursing (DON) acknowledged that the IDT's recommendation was not followed, and the Dietary Consultant confirmed that licensed nurses should have obtained the necessary order to prevent further weight loss. The facility's policy on Weight Assessment and Intervention requires interventions for undesirable weight loss to be based on the resident's nutrition and hydration needs. In this case, the failure to implement the IDT's recommendation and obtain a physician's order for the Glucerna supplement resulted in a lapse in care for a resident at high risk for continued weight loss.