Failure to Provide Ordered Therapeutic Diet After Temporary Downgrade
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, aphasia, and type 2 diabetes did not receive the ordered therapeutic diet. The resident was initially placed on a regular diet with soft, bite-sized textures (IDDSI Level 6) due to their medical condition. Following a dental extraction, a temporary order was placed for a softer, minced and moist diet (IDDSI Level 5) for two days, after which the resident was to resume their normal diet as comfortable. However, after the temporary order ended, the resident continued to receive the Level 5 diet instead of returning to the Level 6 diet as ordered. There was no documented reassessment of the resident's mouth or dental comfort, nor any conversation about diet preferences during this period. Multiple interviews with staff revealed that the process for updating diet orders involved communication between nursing and dietary departments, with orders entered into the electronic health record system and meal tickets printed accordingly. Despite the active order for a Level 6 diet, the resident continued to receive Level 5 meals, and staff could not explain the discrepancy. The resident expressed dissatisfaction with the minced and moist diet, stating it was unappetizing and that they had not been reassessed or consulted about advancing their diet. Facility policy required regular review and documentation of residents' responses to therapeutic diets, but this was not followed in this case.