Inadequate Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct diet consistency for residents on pureed diets, as observed during multiple visits to the main kitchen. The pureed meals prepared for residents did not meet the required smooth, pudding-like consistency as per the facility's policy and guidelines set by the National Task Force. Observations revealed that the pureed hamburger had a grainy consistency, and the pureed vegetables were lumpy. Additionally, the pureed turkey contained small pieces, indicating a failure to achieve the necessary texture. Resident #47, who was on a pureed diet due to a medical condition affecting their ability to swallow, received a meal with a pureed roll that was lumpy and grainy. The resident's meal ticket matched the meal tray, but the consistency did not meet the required standards. Interviews with the Registered Dietitian and Speech Therapist confirmed that the pureed diet should be smooth and lump-free, resembling mashed potatoes, which was not the case during the observations. Resident #175 and Resident #77 also received pureed meals that did not meet the required consistency. Resident #175's meal had a loose puree consistency with liquid pooling around the food, leading to a low intake of the meal. Similarly, Resident #77's meal had a loose puree consistency with liquid pooling, and the resident expressed dissatisfaction with the flavor, resulting in a refusal to eat the rest of the meal. These observations indicate a consistent failure to provide pureed meals in the correct form, potentially affecting the nutritional intake and satisfaction of residents on pureed diets.
Plan Of Correction
F805 FOOD IN FORM TO MEET INDIVIDUAL NEEDS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of the pureed food on the lunch meal tray line, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 2) In the allegation of the pureed food on the lunch meal tray line, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 3) In the allegation of Resident #47, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 4) In the allegation of Resident #175, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 5) In the allegation of Resident #77, the Pureed consistency was considered not to be the proper consistency. Cooks will be in-serviced as to the proper consistency of pureed food. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Cooks will be in-serviced as to the proper consistency of pureed food. Random QA audits will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Dietary Manager or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date: