Failure to Provide Prescribed Diets, Supplements, and Portion Sizes
Penalty
Summary
The facility failed to provide prescribed diets, nutritional supplements, and appropriate portion sizes according to approved menus for seven residents reviewed for weight loss. Multiple observations and record reviews revealed that residents did not consistently receive the dietary supplements, fortified foods, or double portions as ordered by their physicians and dietitians. For example, several residents did not receive fortified pudding, ice cream, or other supplements at meals, despite these being documented on their dietary tickets and care plans. In some cases, residents received food items that were not appropriate for their dietary needs, such as hard taco shells and churros for a resident without teeth, making it difficult or impossible for them to consume the food provided. Residents affected by these deficiencies had significant medical histories, including diagnoses such as Alzheimer's disease, dementia, Huntington's disease, severe protein calorie malnutrition, dysphagia, and chronic obstructive pulmonary disease. Many of these residents were severely underweight or had experienced notable weight loss, with body mass indexes (BMIs) well below healthy thresholds. Despite care plans and dietary orders specifying the need for additional nutrition, such as fortified foods, double portions, and specific supplements, these interventions were not reliably implemented. Family members and staff interviews confirmed that residents sometimes did not receive the prescribed supplements, and in some cases, staff were either unaware of the orders or reported that the supplements were unavailable. Direct observations during meal times further documented that residents were left without necessary assistance to eat, did not receive the correct food textures, and were not provided with the full portions or supplements as ordered. For example, residents requiring supervision or assistance with eating were sometimes left unattended, and those with orders for pureed or mechanical soft diets received foods that were not suitable for their swallowing abilities. These failures contributed to ongoing harm for residents who were already at risk due to their medical conditions and nutritional status.