Failure to Implement Therapeutic Diet Order for Diabetic Resident After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a therapeutic diet was ordered and implemented for a resident with type 1 diabetes upon readmission from the hospital. The resident's hospital discharge summary specified a consistent carbohydrate diet, but upon return to the facility, no diet order was entered into the electronic medical record (EMR) until two days later, when a regular diet was entered. There was no documentation of an order for a regular diet, and the resident continued to receive a regular diet instead of the prescribed diabetic diet. Interviews with nursing staff confirmed that the process for entering and verifying orders, including diet orders, was not followed, and the resident's EMR did not reflect the required therapeutic diet order. The resident, who was independent in all activities of daily living and required insulin for diabetes management, experienced multiple high blood sugar readings during this period. Staff interviews revealed a lack of awareness regarding the resident's dietary needs and the absence of the appropriate diet order. The facility's policy required that diet orders from authorized prescribers be accepted and entered by licensed nurses, but this was not adhered to, resulting in the resident not receiving the prescribed therapeutic diet upon readmission.