Failure to Provide Prescribed Nutritional Supplements and Diet Modifications
Penalty
Summary
The facility failed to ensure that three residents received the prescribed nutritional supplements and diet modifications as ordered by their physicians. One resident, a male with hemiplegia, dysphagia, and GERD, was observed receiving only a single serving of protein at a meal, despite a physician's order for double protein portions. The meal ticket indicated the correct order, but the tray was not prepared accordingly. The staff member responsible for checking trays before serving acknowledged the mistake and confirmed it was his responsibility to ensure accuracy. Another resident, a female with muscle wasting and a history of unplanned weight loss, did not receive the ordered ice cream and shake with her lunch meal. The dietary note and meal ticket both reflected the need for these supplements, but they were not provided during the observed meal service. Similarly, a third resident, a female with primary progressive multiple sclerosis and a history of poor fluid intake and weight loss, did not receive the ordered shake with her lunch. The meal ticket indicated the need for a shake, but the order summary report did not reflect this, and the supplement was not provided. Interviews with nursing and dietary staff revealed confusion and lack of clarity regarding responsibilities for ensuring residents received the correct diets and supplements. Some staff stated that the nurse should check trays before they are distributed, while others indicated that the cook or dietary staff were responsible for certain components. The DON and Administrator both stated that diet orders should be followed and acknowledged that the observed residents did not receive the prescribed supplements and portions. The facility's policy requires that menus meet residents' nutritional needs and be followed as written.