Failure to Order Therapeutic Diet for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a therapeutic diet, specifically a diabetic diet, was ordered for a resident with type 2 diabetes mellitus and hyperglycemia. Upon admission, the resident had discharge instructions from a general acute care hospital indicating the need for a diabetic diet. However, a registered nurse mistakenly ordered a regular standard portion diet instead of the required diabetic diet. This error was identified during a review of the resident's records, which showed that the incorrect diet order was active, and was confirmed by the nurse during an interview. The resident's medical history included metabolic encephalopathy, acute and chronic respiratory failure, type 2 diabetes mellitus with hyperglycemia, and seizures. Both the registered nurse and the Director of Nursing acknowledged the importance of providing the correct diet to address the resident's medical needs. The facility's policy required that therapeutic diets be ordered by a physician and provided in consultation with a dietitian, but this protocol was not followed in this instance.