Failure to Transcribe New Diet Order on Readmission
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for a resident who was readmitted to the facility with new diet instructions following a hospital stay. The hospital discharge summary specified a new diet order for a Dysphagia Carbohydrate Consistent diet, 1600-2000 calories, soft/easy to chew with thin liquids. However, the resident's physician orders in the facility continued to reflect the previous Carbohydrate Consistent Diet with regular texture and thin liquids, and the new diet order was not transcribed into the resident's medical record. Nurse progress notes indicated that the kitchen was notified to resume the resident's previous diet, and interviews with nursing staff revealed that the new diet order from the hospital discharge summary was overlooked. The DON confirmed that it was expected for all nurses to review discharge paperwork to ensure all orders are accurately transcribed, but in this case, the new diet order was missed, resulting in incomplete and inaccurate documentation in the resident's medical record.