Failure to Provide Dialysis Sack Lunch Consistent With Ordered Renal/Dysphagia Diet
Penalty
Summary
The facility failed to provide a diet in accordance with physician orders for a resident with end stage renal disease, dysphagia, and dependence on renal dialysis. The resident’s care plan, dated 04/22/23, directed provision of a Dysphagia Advanced diet with thin liquids, monitoring for signs and symptoms of aspiration, and withholding food and liquids if coughing occurred. A physician order dated 12/18/24 specified a renal diet with dysphagia advanced texture and standard thin liquids. Despite these orders, the resident reported that on days he left the facility for dialysis, he was sent with a sack lunch containing a sandwich that he could not eat because he could choke. The Dietary Manager stated that all dialysis residents are sent with a sack lunch and that this resident received a turkey or peanut butter sandwich, graham crackers, and applesauce. She stated it was her responsibility to review residents’ diet orders and that her expectation was for all diet orders to be followed. The DON confirmed the resident’s renal/dysphagia advanced diet and dysphagia diagnosis, and acknowledged the resident was sent to dialysis three times weekly. The DON was unaware of the specific contents of the sack lunches and stated that while a resident on a dysphagia/renal diet could eat a peanut butter sandwich, a turkey sandwich would not be appropriate due to sodium content and potential for choking. Dietary staff and nursing leadership lacked awareness of and oversight over the dialysis sack lunch contents, resulting in food items inconsistent with the ordered renal/dysphagia advanced diet being provided.
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