Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were prepared and served according to physician orders for two residents who required modified protein portions. One resident, a male with a history of right leg amputation and at risk for malnutrition, had a physician order for double meat/protein portions at all meals. Despite this, he received only half a serving of the entrée during a lunch observation, and both the resident and staff confirmed that he had not previously received double portions as ordered. The dietary manager and the Director of Food and Nutrition acknowledged the error, noting that the resident should have received four cheese manicottis instead of one, and that the correct meal ticket was not used during tray preparation. Another resident, a male with chronic ulcer, depression, hypertension, and anxiety, also had a physician order for large protein portions with meals. During a lunch service, he did not receive the required large protein portion until after surveyor intervention, at which point an additional serving was provided. The resident reported that he did not normally receive that much food, indicating a pattern of not receiving the ordered diet. Both the dietary manager and the Director of Food and Nutrition confirmed the expectation for double or large protein portions and recognized the importance of following diet orders for nutritional needs. Interviews with the dietitian, medical director, DON, and administrator all confirmed that the expectation was for diet orders to be followed as written, with double or large protein portions provided to these residents. The facility's own policy specified that double servings of entrée/protein portions should be served for residents on large portion diets. The failure to provide the prescribed diet as ordered was observed directly by staff and surveyors, and acknowledged by facility leadership.