Failure to Follow Physician-Ordered NPO and Fluid-Restricted Diets
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets for two residents. One resident had diagnoses including malignant neoplasm of the esophagus, dysphagia, and dementia, with a BIMS score of 2 indicating significant cognitive impairment, and a physician order dated 12/9/25 for nothing by mouth (NPO). Despite this order, the resident’s representative reported three occasions when staff attempted to give the resident food or fluids, and the grievance log documented that the family filed grievances in December 2025 and January 2026 after the resident received meal trays on two separate occasions. The Social Service Director confirmed that the resident had received trays on both occasions, contrary to the NPO order. The second resident had diagnoses including ESRD with dependence on dialysis, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic hepatitis, and dementia, with a BIMS score of 5 indicating significant cognitive impairment, and was on a therapeutic diet with a physician order for a 1000 ml fluid restriction per 24 hours, divided between nursing and dietary. During observation, this resident was served a lunch tray with multiple cans of ginger ale and an additional cup of hot chocolate placed on the tray by a CNA, who stated the resident could have what he wanted and that he got enough, when asked about fluid restrictions. Another CNA stated that the computer system and tray ticket identify diet and fluid restrictions and that the resident could have what he liked with meals, just nothing in between. Record review showed no documentation of physician or family notification regarding the resident’s noncompliance with fluid restrictions. The RD and DON both stated that residents should receive diets as ordered by the physician and that notification should occur when there is noncompliance, but the RD acknowledged knowing of the resident’s noncompliance without having spoken with the dialysis center, physician, or family.
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