Failure to Provide Pureed Food Consistency for Residents on Pureed Diets
Penalty
Summary
The facility failed to provide pureed food in the appropriate consistency for residents on pureed diets, as required by their dietary orders and facility policy. During observation of the lunch tray line, regularly prepared gelatin without canned fruit was served to four residents on pureed diets, rather than the required pureed gelatin. The gelatin served was firm and held its shape, indicating it was not pureed. Interviews with the Dietary Manager and Cook confirmed that the gelatin for pureed diets was not pureed, but simply served without fruit, contrary to the recipe and spreadsheet instructions. The Registered Dietitian emphasized the importance of following recipes and spreadsheets to ensure correct food consistency for residents with swallowing difficulties or who are at higher nutritional risk. The residents affected had diagnoses including dysphagia, cerebrovascular disease, chronic obstructive pulmonary disease, seizures, dementia, and other conditions requiring pureed diets with specific liquid consistencies. Their physician orders and meal tickets documented the need for pureed diets, and facility documentation specified that pureed fruited gelatin should be served, prepared according to a standardized recipe. Facility policies required that food be provided in a form designed to meet individual needs and that standardized recipes be followed, but these procedures were not adhered to in this instance.