Failure to Provide Physician-Ordered Dietary Supplements During Meal Service
Penalty
Summary
The facility failed to provide physician-prescribed health shakes to five residents during meal service. On observation, none of the five residents received their ordered dietary supplements with their meals, despite having physician orders specifying the need for health shakes or supplements such as diabetic shakes or Med Pass 2.0. Interviews revealed that the dietary manager had prepared the shakes and placed them on the cart, but the aides delivering the trays did not check the meal tickets to ensure the correct supplements were provided. One resident reported that the shakes are often forgotten. The affected residents had various diagnoses, including aphasia, cerebrovascular disease, diabetes, dementia, schizoaffective disorder, hemiplegia, and alcohol-induced disorder. Their cognitive and physical abilities ranged from severely impaired to cognitively intact, with most requiring some level of assistance or supervision with eating. Facility policy required staff to verify that the correct tray and diet matched the resident's needs at delivery, but this procedure was not followed, resulting in the omission of prescribed dietary supplements.