Failure to Provide Physician-Ordered Therapeutic Diet Due to System Update Error
Penalty
Summary
The facility failed to ensure that a resident received and consumed foods in accordance with the therapeutic diet prescribed by the physician. The resident, who had diagnoses including type 2 diabetes mellitus, end stage renal disease, and hypertensive heart and chronic kidney disease, was ordered to be on a renal diabetic diet with regular portion size. However, staff did not update the resident's diet in the system, resulting in the resident receiving a large portion diet instead of the prescribed regular portion. This discrepancy was observed during a meal service, where the meal ticket and tray provided to the resident indicated a large portion, contrary to the physician's order and the facility's diet list. Interviews and record reviews with the Dietary Supervisor confirmed that the resident's diet order had been revised to a regular portion, but the system was not updated, and the resident continued to receive large portions. The Dietary Supervisor acknowledged that the large portion diet was intended for residents needing more protein and calories, which was not appropriate for this resident's medical condition. The facility's policies required periodic review of tray cards and physician orders to ensure consistency, but this process failed, resulting in the resident not receiving the correct therapeutic diet as ordered.