Failure to Provide Appropriate Meal Textures
Penalty
Summary
Oak Hill Center for Rehabilitation and Nursing failed to meet the requirements for providing meals in a form designed to meet individual needs, specifically for residents requiring mechanical soft and pureed diets. On April 22, 2025, during lunch service, the facility served a mechanical soft meal that did not adhere to the planned menu textures. The chicken enchilada casserole was served with a whole flour tortilla instead of being chopped, and the black beans were served whole rather than ground. This was confirmed by the Nursing Home Administrator during a staff interview. Additionally, a resident with diagnoses including diabetes type II and essential hypertension was affected by this deficiency. The resident had been downgraded to a pureed diet due to difficulty swallowing, as noted by a speech therapist. However, the resident was served a mechanical soft diet instead of the required pureed diet. The dietary slip used during meal tray-line service was outdated and incorrectly listed the resident's diet, leading to the resident receiving the wrong meal texture. The error was identified and corrected during the meal service, but it highlighted a failure in communication and adherence to dietary orders.
Plan Of Correction
1) Facility cannot retroactively correct. Updated diet tickets were immediately printed for current residents. 2) Director of Nursing/Dietary Manager/Designee conducted an audit of current residents' diet orders to ensure they were accurate on newly printed diet slips and to ensure that no other residents received an inaccurate diet. No other concerns were identified. 3) NHA/Designee reeducated the dietary manager and dietary staff on the components of this regulation with an emphasis on ensuring that dietary tickets are printed daily so that they may accurately reflect the residents' most recent diet order. 4) NHA/Designee will conduct random audits of 5 residents' meal trays and tray tickets 3x a week x 4 weeks, then once a week x 2 months to ensure that tickets have been printed daily, and that residents have received the correct physician-ordered meal. The findings of these audits will be brought to the QAPI committee monthly or until substantial compliance is met and maintained. Auditing schedule to be modified if needed.