|§483.60(e) Therapeutic Diets|
§483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.
§483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.
Based on a review of clinical records, a facility investigation and staff interview, it was determined that the facility failed to ensure that a therapeutic diet was provided as ordered by the physician to meet the needs of one resident (Resident 61) out of 14 sampled residents.
A review of the clinical record revealed that Resident 61 had diagnoses that included dementia and dysphagia (difficulty in swallowing). The resident was admitted to the facility on August 29, 2017 and re-admitted on April 30, 2018. The physician prescribed diet order dated March 27, 2019, was for a NAS (No Added Salt) diet Puree texture (pureed diet allows foods with a "pudding-like" texture. The food is smooth and moist Foods should not be coarse, dry, crunchy, sticky, runny, or chewy) mechanical soft meats only (physically soft food/ground/chopped with the goal of reducing or eliminating the need to chew the food), gravies and sauces with all meals.
Review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to identify specific resident care needs) dated February 6, 2019, indicated that the resident was cognitively intact with a BIMS (brief screen that aids in detecting cognitive impairment) score of 15 (score of 13-15 is indicative of intact cognition), required meal set-up by staff with eating, had no swallowing difficulty and was receiving a mechanically altered and therapeutic diet.
Review of Nurse's notes dated March 5, 2019, at 1:58 p.m. indicated that the resident was eating lunch in the dining room. Nursing noted that the resident was eating at fast pace and coughing on her lunch. Coughing did stop and a referral was made to Speech Therapy for an evaluation and possible treatment.
Review of Nurse's notes dated March 7, 2019, at 1:38 p.m. and 1:56 p.m. indicated that the resident was downgraded to a puree diet following increased coughing with facial color changes, watery eyes, nasal drainage noted, as well as, an increased rate of oral intake.
The physician was made aware and new orders were noted for aspiration precautions per policy (Aspiration means that foods or fluids get into your airway. Aspiration precautions are practices that help prevent these problems) and a video swallow study on March 18, 2019. The resident was placed on aspiration precautions regarding impaired swallowing.
Review of nurse's notes dated March 19, 2019, at 11:01 a.m. indicated that the video swallow test results indicated that the resident had swallowing problems. The results recommended a puree diet, but can trial for a safe upgrade to soft solids with patient use compensatory strategies given by Speech Therapy.
Review of nurse's notes dated March 27, 2019, at 11:01 a.m. indicated that the resident was trialed for over a week on mechanical soft textures following a video swallow test. The resident's diet was upgraded to mechanical soft meat, also adding gravy and sauces to all meals trays. The resident's current diet, at that time, was now a puree diet with mechanical soft meat.
Review of a facility investigation dated April 15, 2019, at 8:05 a.m. indicated that Resident 61 was in the doorway of her room. Staff found that the resident was unable to expel food caught in her throat. The nurse successfully performed the Heimlich maneuver to expel the trapped food. The resident was assessed and no further concerns were noted.
Further investigation by the facility revealed that the resident's meal tray ticket for the breakfast meal on April 15, 2019, indicated puree consistency, but Resident 61 received a regular diet, including coffee cake and a hard boiled egg.
Interview with the director of nursing on May 16, 2019, at approximately 11:45 a.m., confirmed that Resident 61 did not receive the therapeutic, puree diet, as ordered by the physician on April 15, 2019, for the breakfast meal.
This finding is cited as past non-compliance.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 2/1/19, 3/29/19.
28Pa. Code 211.6 (c) Dietary Services.
| ||Plan of Correction - To be completed: 05/16/2019|
Preparation, submission, and implementation of this plan of correction do not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continuously improve the quality of care and to comply with all state and federal regulatory requirements.
1. Resident 61 tray ticket and MD order were reviewed for accuracy.
2. Tray tickets were reviewed and compared to the physician orders for accuracy by the Registered Dietician. The tray line in the kitchen was observed for accurate consistencies according to the tray tickets by the Food Service Supervisor. Random audits were conduct on the units by the nursing staff to ensure tray tickets were read and proper consistencies were delivered.
3. The staff have been in serviced by the nurse educator on the reading of the tray tickets prior to presenting to the meal to the residents. The kitchen staff have been in serviced by the RD on the policy Tray Identification, Tray line Procedure and Therapeutic Diets.
4. Tray line will be audited for accurate diet consistency by the FSS/designee 4 times a week for 4 weeks then monthly thereafter for 3 months. The RD will review MD orders and tray tickets weekly for 4 weeks and monthly thereafter for 3 months. The passing of trays on the units will be randomly audited by nursing staff to ensure the staff is identifying the proper consistency prior to serving the tray. Any areas of concern will be addressed immediately. The findings of the audits will be presented to the monthly QAPI meeting for review.