Failure to Implement Dietitian's Nutritional Supplement Recommendation
Penalty
Summary
A resident with diagnoses including dementia, muscle weakness, depression, altered mental status, and Type II diabetes mellitus was identified as having a nutritional problem or being at risk for nutrition impairment and dehydration. The care plan included interventions such as providing dietary supplements as ordered, monitoring intake, and having a registered dietitian (RD) evaluate and recommend diet changes as needed. On 07/15/25, the RD recommended a trial of a magic cup nutritional supplement twice daily with lunch and dinner for additional nutritional support. Despite this recommendation, a review of the resident's physician orders for July and August 2025 showed no orders for the magic cup supplement. Interviews with the RD and the Director of Nursing (DON) confirmed that the RD's recommendation was not followed up on, and the supplement was not implemented. Facility policy required that RD recommendations be implemented or that reasons for non-implementation be documented in a timely manner, but this was not done in this case.