Failure to Provide Correct Diet Consistency and Assistance Leads to Resident Death
Penalty
Summary
A deficiency occurred when a resident was admitted with a hospital discharge order for a minced moist consistency diet with thickened liquids, but the facility incorrectly transcribed and implemented a diet order for chopped consistency with thin liquids. The facility's policy required that if a resident was admitted with a downgraded diet consistency from the hospital, that recommendation should be resumed and communicated to food service. However, the admissions nurse failed to follow this policy, resulting in the resident receiving the wrong diet. The resident, who had diagnoses including sepsis, Parkinson's disease, and asthma, was a total assist for meals but did not receive assistance during breakfast. The resident was found unresponsive in the dining room, and subsequent hospital records confirmed upper airway obstruction from food, leading to respiratory arrest and death. Interviews with staff revealed that the admissions nurse acknowledged the diet was transcribed incorrectly and that the resident should have been on a ground diet with thick liquids. The certified nursing assistant did not assist the resident with their meal, despite instructions that the resident required total assistance. Observations of sample trays showed no clear difference between chopped and ground consistencies, and both included whole pieces of bread, raising further concerns about the facility's dietary practices. The incident was determined to be Immediate Jeopardy, with the potential to affect all residents on modified consistency diets.