Failure to Provide Prescribed Therapeutic Diet Consistency
Penalty
Summary
A resident with diagnoses of Alzheimer's Disease and dysphagia, who was dependent on staff for all activities of daily living and had a BIMS score indicating they were rarely or never understood, did not consistently receive the prescribed therapeutic diet. Observations showed the resident was served pureed main course foods as ordered, but also received regular textured fruit cocktail and pineapple chunks, as well as a half peanut butter and jelly sandwich. The presence of regular textured foods on the tray was inconsistent with the resident's order for a regular diet with pureed texture and thin liquids. Review of the electronic medical record revealed an active order for daily peanut butter and jelly sandwiches to increase caloric intake, and a separate order for a pureed diet. Interviews with dietary and administrative staff confirmed that the dietary worker failed to identify the incorrect food texture on the tray, and that there was a lack of awareness among dietary management regarding the peanut butter and jelly order. The hospice nurse who wrote the pureed diet order may not have been aware of the existing order for the sandwich, leading to conflicting dietary instructions.