Failure to Clarify Diet Consistency on Admission
Penalty
Summary
The facility failed to ensure that Resident #473 had physician orders for immediate care consistent with their physical status upon admission. The resident's hospital discharge orders and summary contained conflicting information regarding diet consistency, which was not clarified at the time of admission. The hospital discharge summary indicated the resident had thin liquid dysphagia and required a thickened liquid diet, while the nursing home transfer documented a regular diet. This discrepancy was not addressed, leading to the resident being admitted on a regular diet with thin liquids. During a lunch observation, the resident was found consuming thin liquids, which prompted a visitor to question the appropriateness of the diet. A speech language pathologist intervened and removed the thin liquids, indicating a need to verify the resident's evaluation. The facility's triple check system, which involved the Director of Admissions, Director of Nursing, and Nurse Manager, failed to identify and clarify the conflicting diet information. The Director of Nursing and Nurse Practitioner involved in the admission process did not review the discharge summary thoroughly, missing the dysphagia diagnosis. Interviews with facility staff revealed that the admission process involved reviewing hospital orders and summaries, but the conflicting information was overlooked. The Director of Nursing admitted to not reviewing the discharge summary unless new medications were involved, and the Nurse Practitioner did not recall addressing the diet discrepancy. The failure to clarify the resident's diet consistency upon admission posed a risk of choking or aspiration, which could lead to complications.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident identified as #473 diet order was corrected immediately. Resident #473 has since been discharged to a lower level of care. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All new admissions from the previous three months discharge summaries, and physician orders [REDACTED]. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The policy medication physicians orders management has been updated to include reconciliation of hospital discharge orders with the discharge summary and discrepancies to be clarified by physician order. All nursing staff will be educated on policy revisions and changes. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? A weekly audit of the reconciliations will be completed for three months, followed by monthly for three months and quarterly for six months. All audit results will be reported at QAPI. The date for correction and the title of the person responsible for correction of each deficiency: Director of Nursing.