Failure to Follow Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when the facility failed to follow the prescribed therapeutic diet for a resident with multiple medical diagnoses, including Type 2 diabetes and a history of amputation. The resident had a physician's order for a carbohydrate (CHO) controlled, high-protein (Hi Pro) diet with regular texture and thin consistency. Despite this order, direct observation of the resident's meals revealed that the food provided did not match the prescribed diet. For breakfast, the resident received two slices of wheat bread and two strips of bacon, while the lunch meal included two rolls and no cauliflower, deviating from the intended dietary restrictions. Interviews with facility staff, including the Certified Dietary Manager (CDM), revealed a lack of understanding and implementation of the specific diet order. The CDM admitted to not having a CHO controlled diet on the spreadsheet and instead used a Hi-Pro diet as a substitute. The CDM also acknowledged that the number of bread servings provided was incorrect and that substitutions were made without proper guidance. Furthermore, the CDM stated that there was no review of the diets with him and only limited discussion with the facility's dietitian regarding discrepancies between the menu and the electronic health record (EHR) diet orders. The resident was unaware of being on a special diet and reported receiving the same meals as other residents. Review of the facility's menu and the "Nutritional Care Manual" indicated that certain foods, such as salty processed meats, should not have been included in the resident's diet, particularly for those with chronic kidney disease stage 5 (CKD5). The failure to provide the correct therapeutic diet as prescribed by the physician, and the lack of communication and oversight in dietary management, led to the cited deficiency.
Plan Of Correction
Resident #1 prescribed therapeutic diet order was reviewed and updated per physician order. A quality audit of current residents on a therapeutic diet was conducted to ensure the prescribed order is being followed. The Administrator educated the CDM (Certified Dietary Manager) on ensuring that prescribed therapeutic diet orders are being followed. Administrator and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that prescribed therapeutic diet orders are being followed. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.