Failure to Provide Appropriate Food Consistency for Resident
Penalty
Summary
The facility failed to provide food in a form that met the individual needs of a resident, identified as Resident R42, who was ordered a soft and bite-size diet. According to the facility's policy on therapeutic diets, these diets are prescribed by the attending physician to support the resident's treatment and plan of care. Resident R42, who was admitted on August 1, 2023, had diagnoses including high blood pressure, dementia, and Parkinson's disease. The resident's physician's orders dated January 16, 2025, specified a soft and bite-size diet. However, during an observation on January 21, 2025, Resident R42 was served a meal with a pureed food consistency, which did not align with the prescribed diet. The discrepancy was noted during an observation in the dining room, where Resident R42's meal ticket indicated a soft and bite-size diet, but the tray contained pureed food. Additionally, the resident's tray was missing milk. A nursing assistant, Employee E6, acknowledged the inconsistency and stated that the kitchen should have been contacted to correct the meal. The Dietary Manager, Employee E3, confirmed the facility's failure to provide the appropriate food form for Resident R42, as required by the resident's dietary orders.
Plan Of Correction
Tickets will be highlighted to alert dietary staff of varied consistency of food items to residents. Dietary staff will be educated regarding the highlighting of tray tickets to alert consistency needs per tray line and IDDS framework of diets. Daily audits of tickets and trays 10 per day per meal for 2 weeks, then bimonthly for 1 month. Audit results will be reviewed through QAPI for further recommendations. 2/25/25 The dietary supervisor performed an internal audit on ALL "resident tray tickets" and compared them against the resident's current prescribed Diet order, to ensure all resident tray tickets were accurate and "up-to-date" (diet, consistency, alerts and resident specific items). Education completed with all dietary staff to ensure order diet/ticket items are included on all trays. Education completed with dietary staff on the "IDDS framework of diets" and also, how to properly highlight the resident tickets to alert other staff of the varied food consistencies and other resident specific items (weighted utensil; dived dish; bowls..ect). Daily audit of tickets and trays 10 per day per meal for 2 weeks, then bimonthly for 1 month. Audit results will be reviewed through QAPI for further recommendations.