Failure to Obtain and Enter Provider Diet Order for Readmitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter a provider’s diet order into the electronic medical record (EMR) for a newly readmitted resident. The resident, who had emphysema, a history of cerebral infarction, repeated falls, cognitive impairment, confusion, and was oriented only to person, was discharged home and later hospitalized before being readmitted to the facility. Her hospital inpatient discharge summary specified a pureed diet with thin liquids. Upon readmission, a Nursing Re-admission Assessment Tool completed by a nurse documented her nutritional status, including that her usual food intake pattern was probably inadequate, that she had some or all natural teeth, and that she required partial to moderate assistance with eating. However, no provider diet order was entered into her EMR at the time of readmission. Surveyor observations on multiple occasions showed the resident receiving meals despite the absence of a provider diet order in the EMR. At breakfast, she was served a regular, pureed diet and consumed about 25% of the meal. At lunch, she was again served a regular diet with pureed foods and was observed feeding herself while seated in a reclining wheelchair. Review of the EMR confirmed there was no provider diet order in place. The Dietary Manager and Regional Dietary Manager verified that a diet order was missing and that a Communication Form from Nursing to Dietary, completed and signed by a Unit Manager, directed dietary staff to provide a regular diet with pureed textures and thin liquids based on the hospital discharge information. The Unit Manager acknowledged she had relied on the hospital discharge information and the Communication Form to Dietary, but confirmed that a provider’s diet order should have been entered into the EMR upon admission. The DON also stated that the diet order should have been entered into the EMR at admission and identified the lack of a provider diet order as a significant problem.
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