Failure to Provide Qualified Dietitian Services for Residents
Penalty
Summary
The facility failed to provide a qualified dietitian to assess and address the individual nutritional needs of four residents, despite multiple documented recommendations and physician orders for dietary consultations. Clinical record reviews revealed that residents with complex medical conditions, including progressive multiple sclerosis, myxedema coma, dysphasia, type two diabetes, and Alzheimer's disease, did not receive dietary consults during their admissions. In several cases, care plans and progress notes specifically identified the need for dietary evaluation, and providers placed orders or made recommendations for dietitian involvement, but there was no evidence that these consults were completed. Interviews with staff, including the Director of Nursing Services (DNS) and a Nurse Practitioner, confirmed that the facility had not had a dietitian on staff for several months and that residents were not being seen by a dietitian as required. The DNS acknowledged the expectation for residents to be seen by a dietitian on admission, quarterly, and as indicated, but was unable to recall when the last clinical assessment by a dietitian occurred. The lack of dietary consultations persisted despite repeated requests and recommendations from both residents and healthcare providers.