Failure to Provide Prescribed Therapeutic Diets for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to implement dietary recommendations for residents with a history of significant weight loss, resulting in two residents not receiving their prescribed therapeutic diets. Observations revealed that the dietary manager prepared insufficient quantities of pureed chicken nuggets for residents on pureed diets, providing only half the required amount. Meal tickets for both affected residents indicated the need for double portions and specific supplements, but these were not provided during multiple observed meals. One resident with diagnoses including toxic encephalopathy, dysphagia, and dementia experienced significant weight loss over several months. Despite a registered dietitian's recommendation for double portions to address ongoing weight loss, the resident consistently received only regular pureed diet portions at meals. Documentation confirmed the resident's weight had decreased by over 10% in four months, and the care plan included interventions to increase meal portions, which were not followed. Another resident with major depressive disorder, complete loss of teeth, and severe underweight status was also affected. This resident's meal ticket specified a pureed diet with double portions, two bowls of super cereal at breakfast, and ice cream at lunch and dinner. Observations showed the resident did not receive the required double portions, super cereal, or ice cream during meals. The registered dietitian confirmed that these interventions were necessary to address the resident's significant weight loss, but the dietary recommendations were not implemented as ordered.