Failure to Follow Therapeutic Diet and RD Supplement Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with the ordered therapeutic diet and nutritional supplements. The resident, admitted with diagnoses including paraplegia, COPD, essential hypertension, and neuromuscular bladder dysfunction, had a physician’s order dated 10/25/2025 for a no added salt (NAS) diet with regular texture, thin liquids, and double meat, with paper tray setup. The resident’s care plan also specified that the diet should be served as ordered. On observation of a lunch meal on 02/23/2026, the resident’s meal ticket listed NAS, regular texture, and thin liquids but did not include the double meat order, and the tray contained only one piece of fried chicken breast. The resident stated he never receives double portions of meat, and the dietary manager confirmed that the resident’s diet included double meat and that it should have been on the meal ticket but was not. The facility also failed to implement and/or document the registered dietitian’s recommendations for oral nutritional supplements and weight monitoring. RD notes dated 12/23/2025 and 01/23/2026 recommended adding Boost/Ensure twice daily between meals to provide additional protein and calories for wound healing and weight maintenance, along with weekly weights for four weeks. The RD later confirmed she had provided these recommendations to the facility. Review of the record showed no documentation that these recommendations were transcribed into physician orders or, if not approved, documented in nursing notes. The DON confirmed that the resident did not have an order for Boost/Ensure twice daily, despite the RD’s recommendations.
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