Failure to Provide Ordered Nutritional Supplement and Honor Resident Menu Preferences
Penalty
Summary
A resident with diagnoses including dysphagia, dementia, depression, malnutrition, and anxiety experienced a significant weight loss of 16 pounds over 180 days. The resident was on hospice services, required total assistance with feeding, and had a physician's order for a regular diet with thin consistency, finger foods as needed, and a magic cup nutritional supplement at lunch. During a lunch observation, the resident did not receive the ordered magic cup, and the CNA assisting her did not notice its absence. The meal ticket clearly indicated the need for the supplement, but the kitchen did not send it, and the dietary aide responsible for reading the ticket and placing supplements on trays did not ensure it was provided. Additionally, the resident's care plan included having a family member complete weekly menus to honor her food preferences and intolerances. However, the family member reported that he had not been given the opportunity to fill out menus recently, resulting in the resident being served items she did not like or would not eat. The Dietary Manager confirmed that menu packets were not consistently provided to the family member as agreed, missing at least three times, including the current week. The facility's policy required providing nutritional and dietary supplements consistent with assessed needs, but this was not followed for the resident.