Failure to Provide Prescribed Dysphagia Diet After Hospital Readmission
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, diabetes, and Parkinson's disease, was readmitted to the facility with new dietary orders following a hospital stay. The hospital discharge summary specified that the resident required a dysphagia carbohydrate-consistent, soft/easy to chew diet with thin liquids due to aspiration risk. However, upon readmission, nursing staff failed to transcribe and communicate the new diet order, resulting in the resident receiving a regular texture diet for two days instead of the prescribed dysphagia diet. The facility's policies required that all diet orders be communicated to the dietary department and that documentation in the medical record be complete and accurate. Interviews and record reviews revealed that the nurse responsible for the resident's readmission overlooked the new diet order and instructed the kitchen to resume the previous regular diet. Another nurse later identified the discrepancy after reviewing the discharge paperwork and completed a diet requisition form for the correct diet, but this was not done until two days after readmission. The Food Service Director confirmed that the kitchen was not informed of the new diet order until the morning of the third day, resulting in the resident receiving the incorrect diet for two days. The Director of Nursing was unaware of the new diet order and acknowledged that two nurses should have reviewed all orders to prevent such errors.