Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to follow the physician's diet order for a resident who was admitted with adult failure to thrive, moderate protein-calorie malnutrition, and a stage two pressure ulcer. The resident was assessed as severely cognitively impaired, required assistance with eating, and was at risk for weight changes. The registered dietitian recommended, and the physician ordered, double portions at breakfast and participation in the enriched meal program, which included specific items such as oatmeal and chocolate milk. However, during observation, the resident's breakfast tray did not include all items listed on the diet card, specifically missing oatmeal and chocolate milk, and did not provide the correct double portions of bacon and French toast sticks. Additionally, the tray included cheese grits, which was a documented dislike for the resident, and did not provide the appropriate substitute for the enriched meal program. Interviews with staff revealed a lack of understanding of the enriched meal program and a failure to ensure that the food served matched the diet card instructions. The dietary manager confirmed that the resident should have received different items and substitutions based on the resident's preferences and the diet order. The registered dietitian also confirmed that the meals served should match the diet card, and the administrator acknowledged that the food served should align with the physician's order and diet card. These findings indicate that the facility did not ensure the resident received the prescribed therapeutic diet as ordered by the physician and recommended by the dietitian.