Failure to Provide Prescribed Therapeutic Diet to Resident
Penalty
Summary
A deficiency occurred when a resident with a history of choking and moderate cognitive impairment was not provided with the prescribed ground textured diet as ordered by the physician. The resident had experienced a choking episode that required an abdominal thrust, leading to a referral for a swallowing assessment by a Speech Language Pathologist (SLP). The SLP recommended a ground diet with moistened soft bread, and the physician's order specified a ground texture diet with thin liquids and moistened soft bread allowed. Facility policies and dietary manuals indicated that hard or crunchy foods, such as potato chips and potatoes with skins, should be avoided for residents on a ground diet. Despite these orders and guidelines, the resident was repeatedly observed being served and consuming food items not permitted on a ground diet, including whole unmoistened muffins, potato chips, and potatoes with skins. These observations occurred over several meals, and the resident was not offered appropriate alternatives or had their food prepared according to the prescribed modifications. The meal ticket for the resident indicated the correct diet, but the actual food served did not comply with the dietary restrictions. Interviews with facility staff, including the SLP, Food Service Director, and Unit Manager, confirmed that the resident should not have received these prohibited items without a physician-ordered exception or waiver. Staff acknowledged that the process for obtaining exceptions or waivers was not followed prior to serving the restricted foods. The medical record did not indicate that the physician was aware the resident was being served items not permitted on the prescribed diet until after the surveyor brought the issue to the facility's attention.