Failure to Provide Ordered Nutritional Supplement at Lunch
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed nutritional supplement according to physician orders for one resident reviewed for dining. The resident was admitted with severe vascular dementia with agitation and had severe cognitive deficits documented on the MDS. The resident’s care plan identified that she was at nutritional risk for weight loss related to poor intake secondary to dementia, with an intervention specifying supplements or alternates per order. Current physician orders included a diet order for regular texture, regular liquid consistency, with fortified pudding to be added at lunch. During an observed lunch meal service in the dining room, the resident, who was alert and oriented only to herself, received a regular texture lunch tray. The diet card for this resident specified that the tray should contain fortified pudding at lunch, but the fortified pudding was not present on the tray. A dietary aide confirmed that all residents in the dining room had received their trays and acknowledged that this resident should have received fortified pudding. The facility’s Food and Nutrition Services policy stated that each resident is to be provided a diet that meets daily nutritional and special dietary needs, based on a multidisciplinary assessment and a resident-centered diet and nutrition plan, but the ordered fortified pudding supplement was not provided as required.
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