Resident Placed on Incorrect Mechanically Soft Diet Due to Documentation Error
Penalty
Summary
A resident with a history of acute osteomyelitis, ESBL-producing E. coli infection, metabolic encephalopathy, and acute kidney failure was admitted to the facility and was mistakenly placed on a mechanically soft diet. The resident's hospital discharge summary indicated a regular diet, and the initial screening by the registered dietitian found no issues with chewing or swallowing. However, the speech therapist erroneously continued a mechanically altered diet order from a previous admission, based on incorrect information in Section K of the MDS and without current speech therapy progress notes. As a result, the resident received a mechanically soft diet that was not clinically indicated, leading to poor meal consumption, with records showing less than 50% of meals eaten on multiple occasions. The resident expressed dissatisfaction with the mechanically soft diet and relied on family to bring in food, as he did not like or eat the meals provided by the facility. The error was only identified and corrected after surveyor intervention.