Inadequate Pureed Diet Consistency for Residents
Penalty
Summary
The facility failed to provide the correct diet consistency for residents on a pureed diet, as observed in three residents. The pureed Chicken Pot Pie served to these residents was lumpy, and the green beans shell were easily identifiable, which did not meet the required pureed consistency. This inconsistency was observed during meal times in both the main dining room and individual resident rooms. The residents involved had various medical conditions, including Atrial Fibrillation, Gastro-Esophageal Reflux Disease, Combined Systolic and Diastolic Heart Failure, Muscle Wasting and Atrophy, and Hemiplegia following a Cerebral Infarction. All three residents were unable to conduct interviews due to their mental status, as indicated by their Brief Interview of Mental Status (BIMS) scores. The Speech Therapist at the facility confirmed that pureed food should be blended into a uniform consistency, but admitted that no training had been conducted with the kitchen staff since her employment began in July. The District Manager stated that she routinely checks the pureed food consistency before it is served, but the deficiency was still present. The facility's policy referenced the National Dysphagia Diet guidelines, which require a homogenous, pudding-like consistency for pureed foods, a standard that was not met in these instances.
Plan Of Correction
Boca Circle Rehabilitation Center failed to provide the correct diet consistency for the Pureed diet. **Actions Taken:** 1) Resident #35 & #108 remain in the facility in stable condition. Resident #102 no longer resides in the facility. **Others Identified:** 2) Full house was conducted by the Dietary Manager/Designee to ensure the residents diet consistencies were correct. Any concerns identified were immediately addressed. **Measures Taken:** 3) Dietary Staff were in serviced on ensuring the residents diet consistency is accurate by Certified Dietary Manager. Nursing staff were re-educated to monitor diet consistency during meal tray check/pass. Newly hired dietary staff and nursing staff will receive this education during general orientation. **Ongoing Monitoring:** 4) The Dietary Manager/Designee will conduct daily audits 5X/week to verify that residents diet consistencies are correct x 4 weeks, and then 2X/week for 2 weeks then weekly for 2 months. Audit results will be reviewed in Center QAPI meeting until substantial compliance has been met.