Failure to Provide Ordered Nutritional Interventions and Assess Dietary Preferences
Penalty
Summary
The facility failed to ensure a resident was adequately assessed for dietary needs and provided nutritional interventions as ordered by the physician. The resident was admitted with multiple diagnoses including stroke with hemiplegia and hemiparesis, dysphagia, hepatitis C, and alcohol abuse. A physician’s order dated 12/31/25 specified a regular diet with mechanical soft texture, regular consistency, no plain eggs, bacon, or milk products, extra gravy and sauces, yogurt on the breakfast tray, and ice cream on the lunch or dinner tray. Skin & Weight Notes documented significant weight loss of 5% in 30 days and then 6% in one month, with oral intake ranging from poor to fair and 26–75%. The dietitian recommended adding a strawberry health shake twice daily, and the care plan included yogurt, ice cream, and health shakes as part of the resident’s nutritional support. Despite these orders and interventions, surveyor observations showed that the resident’s lunch tray on one date did not include ice cream or a health shake, and the breakfast tray on another date did not include yogurt or a health shake. The Dietary Manager (DM) stated the resident had previously been served milk shakes, yogurt, and ice cream, but after receiving a communication from the Speech Language Therapist indicating no eggs, bacon, or milk products due to diarrhea, the resident was no longer served the milk-based health shake. The DM also stated the facility did not have non-dairy nutritional supplements and acknowledged she did not inform the Administrator about this lack of non-dairy options, though she believed she should have. Additionally, the resident’s Dietary Profile documented a preferred beverage (orange juice) but did not include food likes and dislikes, and the DM confirmed she did not obtain this information from the resident’s representative when the resident was unable to provide it herself.
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