Failure to Communicate and Implement Physician's Dietary Order
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to maintain acceptable parameters of nutritional status for a resident with multiple diagnoses, including dysphagia, unspecified psychosis, and major depressive disorder. The resident was totally dependent on staff for self-care and had severely impaired cognitive skills. A physician's order was issued to provide a large portion at breakfast, following a recommendation from the registered dietitian to meet the resident's nutritional needs. Despite the physician's order, the kitchen staff did not receive notification of the dietary change. The kitchen supervisor confirmed that the resident's meal tray card did not reflect the large portion order and stated that no communication or ticket had been received from the nursing department regarding the new order. The registered dietitian and the director of nursing both explained that the process requires nursing staff to communicate dietary orders to the kitchen for implementation, but this step was missed in this case. The registered nurse confirmed that the order for a large portion breakfast was not carried out until several weeks after it was written. Facility policy requires that residents receive care and services consistent with their comprehensive assessment and care plan, including dietary needs. The failure to communicate and implement the physician's order resulted in the resident not receiving the prescribed large portion breakfast for an extended period.