Delayed Diet Order Entry Resulted in Late Meal Service for Readmitted Resident
Penalty
Summary
The facility failed to timely input a resident's diet order upon readmission, resulting in a delay in meal service. Specifically, a resident with diagnoses including dementia, dysphagia, and type 2 diabetes mellitus was readmitted to the facility, but the licensed nurse did not enter the required diet order into the electronic health record or submit a diet slip to the kitchen. As a result, the kitchen was unaware of the resident's dietary needs, and the resident did not receive a breakfast tray at the scheduled time. The resident ultimately received breakfast two hours after the scheduled mealtime, as observed by staff and confirmed through interviews and record review. The resident's medical records indicated a need for a mechanically altered, consistent carbohydrate, no added salt diet due to diabetes and swallowing difficulties. Staff interviews revealed that the process for ensuring timely meal delivery was not followed, as the admitting nurse did not input the diet order or notify the kitchen. The delay was only identified during morning rounds, after which the diet order was entered and the meal provided. Facility policy required regular meal times and prompt communication of dietary needs, which was not adhered to in this instance.