Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when a resident who was prescribed a consistent carbohydrate diet with no added salt by their physician was served an incorrect dessert during lunch. The resident's meal ticket indicated the need for a consistent carbohydrate diet, and the facility's menu spreadsheet specified that the appropriate dessert for this diet was two pear halves. However, the resident was observed eating a blueberry streusel dessert instead. During the observation, an LVN confirmed that the resident was supposed to receive a consistent carbohydrate diet but did not have access to the menu spreadsheet to verify the specific food items. The LVN relied solely on the meal tray ticket and diet list, which did not specify the correct dessert. The Director of Staff Services (DSS) later verified that the resident should have received two pear halves, confirming the discrepancy between the physician's order and the food served.
Plan Of Correction
The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 93 was affected by this deficient practice. Immediately on 7/15/2025, RN supervisor assessed and observed resident for any adverse reaction and no issue was noted. On 7/15/2025, Registered Dietitian in-serviced all dietary staff about P&P for therapeutic diet and making sure all residents diet slip was being followed. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents receiving consistent carbohydrate diet were potentially affected by this deficient practice. On 7/15/2025, RD and Dietary supervisor audited all resident receiving Consistent carbohydrate diet and found no other issue noted. On 7/25/2025, RD and Dietary supervisor implemented new process of putting label for all dessert appropriate for resident with consistent carbohydrate diet order to make it easier for floor staff to recognize and address the issue if resident received inappropriate meal. On 7/25/2025, 7/28/025-7/31/2025, RD and Dietary supervisor in-serviced all Dietary staff, and Nursing department regarding P&P for therapeutic diet and the implementation of new process for recognizing dessert for resident with consistent carbohydrate diet order. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON and Registered Dietitian or designee will oversee this process. RN supervisor or designee will review all new admission and readmission diet order and RD will follow up for therapeutic diet. IDT team will discuss all new resident with therapeutic diet during clinical meeting (M-F) making sure plan of care was in placed. Dietary supervisor will make sure diet order and diet slip is accurate during meal tray line daily and Licensed nurse on the floor will double check every meal to make sure resident is receiving correct meal based on their physician therapeutic diet order. Any non-compliance will be reported to DON daily x 3 months. Facility plans to monitor effectiveness of the corrective actions and sustain compliance: Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025