F0808

D

Failure to Follow Hospital Dysphagia Diet Recommendation for New Admission

Kingsland, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a prescribed therapeutic diet for one resident with significant medical conditions and dysphagia. The resident, an older male admitted from the hospital with diagnoses including Type 1 diabetes with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension, had a hospital Speech-Language Pathology recommendation for a diet of thin liquids and pureed consistency. The admission MDS showed a BIMS score of 09, indicating moderate cognitive impairment, and the care plan later reflected ADL self-care deficits and moderate fall risk related to confusion. The facility’s policy required therapeutic diets to be prescribed by the attending physician or delegated dietitian and that diet orders match food and nutrition services terminology, including altered consistency diets.

On admission, the communication of the resident’s diet from nursing to dietary was incorrect. A dietary communication slip dated 12/27/2025, completed by LVN B, indicated a regular/liberalized, no concentrated sweets (NCS), regular texture diet with thin liquids, rather than the pureed texture recommended by the hospital. The Dietary Manager stated that for new admissions, dietary relies on the dietary communication slip from nursing and does not review the clinical record directly. Based on this initial slip, the resident received regular texture food from 12/27/2025 through 12/31/2025. During this period, the physician order dated 12/31/2025 later reflected a regular diet with pureed texture and regular liquid consistency, and the care plan initiated 01/05/2026 documented an NCS diet with pureed texture and thin liquids.

Interviews confirmed that the admitting nurse and dietary staff depended on the information transmitted via the dietary communication slip rather than verifying the hospital discharge recommendations. LVN C, identified as the admitting nurse, stated she would have looked at the discharge papers to determine the diet but could not recall the resident’s admitting diet or whether she received a nurse-to-nurse report. The Dietary Manager confirmed that the resident’s meals were prepared as regular texture until a subsequent dietary communication slip dated 12/31/2025 changed the diet to pureed texture with thin liquids. The Regional Nurse stated that the admitting nurse was responsible for sending the correct diet order to dietary based on the hospital clinical information and should have called the hospital for clarification if unsure. Staff interviews noted that providing regular texture food instead of pureed for a resident requiring pureed texture created a risk for aspiration, choking, and weight loss.