Failure to Provide Ordered Fortified Foods to Residents at Nutritional Risk
Penalty
Summary
The facility failed to provide ordered fortified foods to six residents who had recommendations and care plan interventions for fortified foods to address nutritional risk, weight loss, or inconsistent intake. During meal service observations on the 2nd floor dining room, residents identified as R18 and R95 had meal tickets indicating "fortified pudding" but did not receive it, and R78’s meal ticket indicated "magic cup" but she did not receive it. During meal service observations on the 3rd floor dining room, residents identified as R35, R45, and R64 had meal tickets indicating "fortified pudding" but did not receive it. The Registered Dietitian (V17) stated that when she recommends fortified foods, she enters these recommendations into the kitchen platform so they appear on the facility meal tickets, and that fortified foods do not appear on the Physician Order Sheet but should be provided if they appear on the meal ticket. The Assistant Dining Service Director (V6) stated that the facility no longer has magic cup, that residents are to receive fortified pudding instead, and that servers are supposed to plate fortified pudding in bowls and place them on the tray with the rest of the meal. Despite this, the fortified items indicated on the meal tickets were not served to the identified residents. Care plans for all six residents documented nutritional concerns and included interventions to provide fortified foods: R18 and R95 were noted to be at increased nutritional risk or at risk for unintentional weight loss related to advanced age, impaired cognition, and variable intake; R35, R45, and R64 had histories of inadequate intake and weight loss; and R78 had inadequate intake related to early satiety with observed 50% meal consumption. The Registered Dietitian confirmed that she recommended fortified pudding or magic cup for these residents due to either past significant weight loss or inconsistent intake, and that if fortified foods appear on the meal ticket, the resident should receive them.
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