Failure to Provide Therapeutic Diets as Prescribed
Penalty
Summary
The facility failed to provide therapeutic diets according to physician orders for two residents, leading to deficiencies in dietary services. Resident #1, who was admitted with medical diagnoses requiring a specific diet, did not receive the prescribed pureed texture and double portion protein/entrée at each meal. During an observation, Resident #1 was given a mechanical soft diet instead of the required pureed diet, and staff were unaware of the resident's dietary needs. The Dietary Manager was not informed of the diet change, resulting in the resident receiving incorrect meal portions. Resident #25 also did not receive the prescribed double portions of protein as indicated in the physician's orders. Despite the meal ticket specifying double portions, the resident received only one patty of Salisbury steak instead of two. The Registered Dietician confirmed that the resident should have received double portions due to previous weight loss and the need for increased nutritional intake. The facility's dietary staff failed to follow the meal ticket instructions, leading to the resident not receiving the necessary dietary support. The facility lacked a policy and procedure for following and honoring meal tickets and diets, contributing to the oversight in providing the correct meals to residents. The dietary staff, including the Cook and Dietary Aide, were unable to explain how the error occurred, indicating a lack of communication and oversight in the dietary service process. The absence of a structured protocol for ensuring dietary orders are followed resulted in residents not receiving the appropriate nutrition as prescribed by their physicians.
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 increase in or No decrease in SPO2 noted. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service. (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 entrée. Quality review completed by the DON/designee r/t 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 entrée. 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 r/t 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.