Failure to Notify Resident Representative of Diet Change
Penalty
Summary
The facility failed to notify a resident's representative of a change in the resident's diet, as required by policy. The resident, who had a history of diabetes mellitus type 2, transient cerebral ischemic attack, Parkinson's disease, muscle weakness, and dysphagia, was assessed as moderately cognitively impaired and required assistance with daily activities. The care plan indicated the resident was at risk for nutrition-related problems and that the family had declined a recommended NPO diet, opting instead for regular chopped textures after being educated on the risks. Despite this, the resident's meal card specified a mechanical soft chopped diet for all meals, and the resident's representative was not informed of this change. Interviews with the resident and their family revealed confusion and lack of awareness regarding the diet being served. The family specifically stated they were not notified of the change from a regular to a mechanical soft diet. The NHA confirmed that the diet change was recommended following a speech language pathology evaluation and acknowledged that the family had not been notified. Review of facility policy showed that notification of a resident's representative is required when there is a significant change in the resident's status, which did not occur in this instance.