Failure to Verify and Continue Correct Therapeutic Diet on Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure a therapeutic diet was accurately clarified and continued upon admission for a resident transferred from another SNF. The resident was admitted with chronic congestive heart failure and Alzheimer’s disease and was severely cognitively impaired, requiring extensive to total assistance with mobility, ADLs, and eating. On admission, the Assistant Director of Nursing (ADON) entered an order for a pureed diet with thin liquids based solely on a verbal report from an unknown staff member at the sending facility, who stated the resident required one-on-one feeding and was on a pureed diet. The admission documentation received from the sending facility included only a facesheet and a medication list and did not contain the order summary or any written diet order. The facility’s own policy required that transfer records include nursing and dietary information in sufficient detail to provide continuity of care, and that if specified records were not received, staff were to contact the sending facility’s discharge planner or health information department to request the missing records. Despite this, no immediate effort was made at admission to obtain the resident’s complete discharge/transfer orders, including the diet order, from the sending facility. Subsequent review of the sending facility’s order summary showed that the resident’s actual diet at discharge was a fortified, soft and bite-sized, liberalized diet with thin liquids, not a pureed diet. A speech therapy evaluation was only ordered after the resident’s family later reported that the resident had not been on a pureed diet at the prior facility. The speech therapy evaluation then trialed a ground mechanical soft/thin liquids diet without signs or symptoms of aspiration and upgraded the diet accordingly. As a result of the initial failure to verify and reconcile the diet order at admission, the resident received an incorrect pureed diet for several days before the discrepancy was identified and addressed.
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