Failure to Provide Prescribed Renal Diet to Resident with ESRD
Penalty
Summary
The facility failed to follow the prescribed renal diet for a resident diagnosed with end stage renal disease (ESRD), spina bifida, and neurogenic bladder. The resident was admitted with orders for a renal diet, regular texture, and thin consistency fluids, as documented in the medical record and care plan. Despite these orders, the resident reported occasionally receiving incorrect menu items during mealtimes. On one observed occasion, the resident was served Italian crusted fish instead of the baked fish specified for the renal diet, and received a double portion of protein per his request. The dietary supervisor confirmed that the Italian crusted fish was not appropriate for the renal diet and that the resident should have received baked fish with simple seasonings. The dietary supervisor acknowledged responsibility for checking plates before food carts left the kitchen and before nursing staff distributed meals, but failed to ensure the correct meal was served. The director of nursing confirmed that not following the therapeutic diet could negatively impact the resident's health, especially given the resident's ESRD and need for dialysis. The facility's policy required all special diets to be prepared and served as planned, but this was not followed in the resident's case.