Failure to Provide Diet Consistent with Physician Orders Results in Resident Harm
Penalty
Summary
A resident with diagnoses including type 2 diabetes and vascular dementia, and a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition, had a physician's order for a minced and moist texture diet with thin consistency due to recent swallowing complications such as coughing and vomiting up food. Despite this order, the resident was provided with a cheese stick and pretzels as a snack after a low blood sugar reading. Both food items were not appropriate for the prescribed diet texture. The nurse, who was training a new nurse at the time, was unaware of the resident's updated diet order. The nurse report sheet only documented how residents took their pills and did not include information about diet texture. The updated diet order was present only in the primary care provider's orders and was not reflected in the nurse report sheet or the treatment/medication administration records. The nurse did not receive any information during shift report about changes to the resident's diet or new swallowing difficulties. After the resident consumed some of the provided snack, staff found the resident choking and unresponsive. Despite attempts to clear the airway and perform the Heimlich maneuver, the resident passed away. The facility's investigation determined that the incident occurred because the nurse did not have access to the resident's texture restrictions at the point of care, as this information was not readily available or communicated to nursing staff.