Failure to Provide Prescribed Nutritional Supplements per Care Plan
Penalty
Summary
The facility failed to provide nutritional supplements as documented in a resident's care plan and Dining Detail. Specifically, a resident with diagnoses including Parkinson's with dyskinesia, dementia, dysphagia, and chronic pain was not given prescribed supplements such as vanilla ice cream and mashed potatoes with gravy (super spuds) with lunch and dinner, as well as in-house shakes at 2 p.m., despite these being clearly outlined in both the care plan and the Dining Details Report. The care plan had been updated multiple times to reflect the resident's preferences and nutritional needs, including the removal of ice cream at breakfast per the resident's wishes, and the continuation of ice cream and super spuds with lunch and dinner, along with a daily shake. During the survey, direct observation of the resident's lunch revealed the absence of both super spuds with gravy and vanilla ice cream, with only a sandwich, a drink, and sliced peaches present. Interviews with staff confirmed that these supplements were not provided at the observed meal. The Assistant Director of Nursing also verified that the required items were missing from the resident's meal tray, acknowledging the concern. The deficiency was identified through review of the complaint, medical record, care plan, and direct observation.