HospitalInspections.org

Based on review of one of ten medical records (Patient (P) 2), and staff interview, it was determined that the facility failed to ensure all patients receive care in a safe setting.

Findings include:

On 8/31/23 at 11:00 AM, a review of the medical record for P2 revealed the following:

P2 was diagnosed with dysphagia on 8/9/23 and ordered a pureed/moderately thick/honey thick diet during admission at an acute care hospital [Hospital 4] prior to his/her admission to this facility. On 8/13/2023, P2 was admitted to the facility, a Long-Term Acute Care Hospital (LTACH).

On 8/13/2023, the nursing admission assessment note completed by Staff (S) 13, a Registered Nurse (RN), at 16:15 [4:15 PM] stated, "Cardiac-puree diet, honey thick liq. (liquids)."

Upon review of the physician's admission orders completed on 8/13/2023, dietary orders written by S6, the Admitting Physician, indicated "PO (by mouth) diet: Cardiac-Regular."

The Initial Nutrition Assessment completed by S14, a Dietician, on 8/15/2023 documented the patient was on a "Heart Healthy" diet.

On 8/22/23 there was a prescription for "Honey thickened diet" written by S15, a Medical Doctor (MD) and acknowledged on 8/23/23 by S13. The dietary orders were changed to "Honey thickened diet" on 8/23/23.

On 8/31/23 at 2:15 PM, S1, the Chief Nursing Executive, confirmed P2 was ordered and received the incorrect diet from 8/13/23 until 8/23/23.