Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet according to physician orders for two residents, leading to deficiencies in their care. Resident #1, who was admitted with medical diagnoses including cerebral infarction and dysphagia, was observed not receiving the appropriate pureed diet and thickened liquids as ordered. Despite the speech therapist's recommendation to downgrade his diet to pureed due to aspiration risk, the dietary manager was unaware of the change, resulting in Resident #1 receiving a mechanical soft diet instead. This miscommunication was attributed to a missing dietary change form, which was not properly processed in the dietary system. Resident #25, who was supposed to receive double portions of protein due to weight loss, did not receive the correct meal portions as per his dietary orders. During a lunch observation, it was noted that he received only one Salisbury steak patty instead of the double portion indicated on his meal ticket. The facility's Registered Dietician confirmed the oversight and acknowledged that the meal ticket was not followed, which should have been caught by the tray line staff. The lack of adherence to the meal ticket resulted in Resident #25 not receiving the necessary nutritional support to address his weight loss. The facility's dietary management process was found to be lacking, as there was no policy or procedure in place for following and honoring meal tickets and diets. The dietary staff, including the cook and dietary aide, were unable to explain how the errors occurred, indicating a systemic issue in the meal service process. The absence of a structured protocol for ensuring dietary orders are accurately followed contributed to the deficiencies observed in the care of both residents.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified resident #1: Resident was provided an additional serving of protein during lunch meal service per physician order. Diet orders were reviewed by the Chief Nursing Officer. Tray ticket updated with Puree diet per physician order and Speech recommendations. Resident did not suffer any adverse effects from not receiving the proper diet texture. Resident #1 was assessed by the APRN. APRN progress notes documented: CTA. No chills or increased in decrease in SPO2 noted. No. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service (205). (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review completed by Certified Dietary Manager/designee to ensure the residents receive meals per physician order, tray tickets match the physician order and residents receive double portions/2x entrees. Quality review completed by the DON/designee ensuring residents are provided with snacks when requested to be completed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Dietary staff re-educated by the Certified Dietary Manager on the components of this regulation and that residents receive meals per physician order, tray tickets match the physician order, tray line validates what is served match the tray ticket and residents receive double portions/2x entrees. When the Dietary Manager is not present, the dietary staff will update the sheet located in the kitchen to document new admissions, re-admissions or diet changes and update the pre-printed tickets with changes, write a ticket with new admissions/re-admissions for the Dietary Manager to input in the tray card system upon return to the center completed. Current Certified Nursing Assistants re-educated by the DON/designee regarding ensuring residents receive snacks upon request to be completed. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; Certified Dietary Manager/designee to conduct ongoing quality monitoring through visual observation of the tray line and meal service in the dining room to ensure residents are provided meals per physician order 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, twice weekly x 4 weeks then weekly and PRN as indicated. DON/designee to conduct ongoing quality monitoring through resident interview and observation to ensure snacks are provided upon request 3 x weekly x 2 weeks, twice weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.