Failure to Implement Physician-Ordered Therapeutic Diet for Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician-ordered therapeutic diet for a resident diagnosed with congestive heart failure, chronic kidney disease, and edema. The resident's medical record included a physician order for a two-gram low sodium diet and a two-liter fluid restriction due to congestive heart failure, but the dietary meal ticket listed the resident's diet as regular. Staff interviews revealed that the new diet and fluid restriction order had been entered incorrectly into the electronic medical record and was overlooked, resulting in the resident not receiving the prescribed therapeutic diet. The process for communicating new diet orders involved notifying dietary and documenting fluid restrictions on the Treatment Administration Record, but this was not followed in this instance. The resident's care plan specified that the facility would provide the diet as ordered by the physician, and the facility's policy required assessment and implementation of nutritional needs based on medical conditions. Despite these requirements, the resident continued to receive a regular diet rather than the ordered low sodium, fluid-restricted diet. Observations confirmed the resident's diet was not consistent with the physician's order, and staff acknowledged the oversight in updating and communicating the new dietary order.