Failure to Notify Resident Representative of Change in Diet Order
Penalty
Summary
The facility failed to notify the resident representative (RR) of a change in condition for one resident. Specifically, the resident's diet was changed to pureed following an evaluation by a speech therapist due to episodes of coughing and vomiting while being fed. The speech therapist documented the swallowing impairment and recommended the diet change, which was then ordered and entered into the system. However, the RR was not informed of this change and only discovered it during a visit when he noticed the resident was receiving a pureed diet. Interviews with facility staff confirmed that the RR had not been notified of the diet change or the reason for it. The speech therapist stated that it was not facility practice for therapists to notify families, and the DON explained that the nurse who confirms the order is responsible for notifying the RR. Due to subsequent clarifications in the order, the original confirming nurse could not be identified. The resident involved had a history of cerebral infarction, dysphagia, and seizures, and was admitted with these diagnoses.