Failure to Provide and Increase Dietary Supplements as Ordered
Penalty
Summary
The facility failed to provide a dietary supplement as ordered and did not implement the dietitian's recommendation to increase the supplement for a resident experiencing weight loss. The resident, who had diagnoses including cerebral palsy, severe cognitive impairment, and severe protein-calorie malnutrition, was on a regular pureed diet with nectar thickened liquids and was supposed to receive a house shake twice daily and Majic Cup with lunch and dinner. The dietitian recommended increasing the house shake to three times daily with meals due to ongoing weight loss, but this recommendation was not implemented. Documentation showed the resident continued to receive the supplement only twice daily, and there was no evidence of the increased frequency being provided. Observation during a meal revealed the resident did not receive the required supplements with lunch, and staff were unaware of the missed supplements and the dietitian's updated recommendation. The process for communicating dietary changes involved verbal and email notifications from the dietitian to the ADON, who was then responsible for ensuring nurses updated orders and dietary slips. However, this process was not followed, resulting in the resident not receiving supplements as ordered or as recommended by the dietitian.