Resident Served Incorrect Diet Due to Lack of Updated Physician Order Documentation
Penalty
Summary
A deficiency occurred when a resident with a physician's order for a mechanically soft textured diet was served a regular textured meal during lunch service. The resident, who had a diagnosis of seizure disorder and a history of dental problems, was observed eating a large lettuce salad with ham, which did not conform to the prescribed mechanically altered diet. The resident's Minimum Data Set (MDS) indicated intact cognition and independent eating, and the dietary order for a regular diet was not documented in the clinical record at the time of the meal service. Staff, including the Licensed Nursing Home Administrator (LNHA) and Assistant Director of Nursing (ADON), acknowledged that the order for a regular diet had not been entered into the resident's record prior to the meal. The ADON confirmed that the order for a regular diet was obtained after the lunch observation. The facility was unable to provide documentation supporting a physician's order for a regular diet at the time of the survey, resulting in the resident receiving a diet inconsistent with the current documented physician's order.