Failure to Follow Dietary Orders and Ensure Proper Communication of Diet Requirements
Penalty
Summary
A deficiency occurred when a resident with a recent Whipple procedure, hernia repair, and PEG tube placement was not provided care in accordance with physician orders and dietary requirements. The resident was admitted with orders for a clear liquid diet and tube feedings, with specific instructions to gradually increase the tube feeding rate if tolerated. Despite these orders, the resident was given a regular meal consisting of a cheeseburger and fries, which was not consistent with the prescribed clear liquid diet. Multiple staff interviews and documentation confirmed that the resident consumed part of this meal and subsequently experienced nausea and vomiting. The facility's process for communicating and verifying dietary orders failed, resulting in the resident receiving the incorrect meal. Staff interviews revealed confusion and miscommunication between the dietary and nursing departments, with discrepancies in how diet orders were transcribed and interpreted. The dietary system listed the resident as having a 'regular' diet, while the medical record and physician orders specified a clear liquid diet. Staff responsible for preparing and delivering meals did not adequately verify the correct diet order before serving the meal to the resident. Following the consumption of the inappropriate meal, the resident experienced ongoing nausea, vomiting, and was later observed with bloody vomitus. Documentation and interviews indicated that the resident's symptoms persisted, and there was a lack of timely and thorough assessment and communication regarding the change in the resident's condition. The resident was ultimately found unresponsive and pronounced deceased. The care plan also failed to address the resident's PEG tube status and feeding requirements, further contributing to the deficiency.