Failure to Provide Prescribed Therapeutic Diets to Multiple Residents
Penalty
Summary
The facility failed to meet the dietary needs of three out of eight residents by not ensuring that prescribed diets were accurately ordered and provided according to each resident's medical requirements. For one resident with diagnoses including heart failure, chronic kidney disease, and high blood pressure, the hospital discharge paperwork specified a cardiac, 2 gm sodium-restricted diet. However, upon admission, the appropriate dietary restriction was not selected in the assessment, and the resident initially received a regular diet without restrictions. The diet order was later changed to a no added salt (NAS) diet only after the deficiency was identified. Another resident with chronic obstructive pulmonary disease, pulmonary fibrosis, and high blood pressure was admitted with no diet order included in the physician's orders, despite the assessment indicating a regular diet. A third resident, admitted with muscle weakness and gait abnormalities, had hospital discharge instructions for a cardiac, moderate carbohydrate, 2 gm sodium, and 1800 mL fluid-restricted diet, but the facility's assessment only indicated a controlled carbohydrate diet, and no diet order was present in the physician's orders until after the issue was raised. These deficiencies were confirmed through review of clinical records, hospital discharge paperwork, admission assessments, and physician orders, as well as interviews with facility administration. The lack of timely and accurate diet orders resulted in residents not receiving diets that met their specific medical and nutritional needs as prescribed, in violation of federal and state regulations regarding food and nutrition services, management, nursing services, resident rights, and dietary services.
Plan Of Correction
Resident R2, R3, and R4 were assessed. No negative outcome resulted from not including diet orders in physician orders. Diets were added in per hospital de records for each resident. An audit was completed to ensure all residents have accurate diet orders in physician orders. Don, or designee, will educate licensed staff on following the physicians' orders policy and verifying orders. The DON, or designee, will conduct an audit to ensure that all new admissions have accurate diet orders per hospital de summary added into physician orders weekly for 2 weeks, then monthly for 2 months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.