Failure to Provide Physician-Ordered Puree Diet Texture
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident with food prepared in the physician-ordered texture, specifically a puree diet with honey thick liquids. The resident, who had diagnoses including dysphagia, chronic kidney disease, and cognitive communication deficit, was assessed as being at high risk for aspiration and required a puree diet and honey thick liquids as per physician and speech therapy orders. The care plan and medical record indicated the need for close monitoring and supervision during meals, with interventions to prevent aspiration. During observation, the resident was served breakfast items that were of minced/chopped consistency rather than smooth and lump-free puree, as required. Both the DON and Dietary Manager confirmed that the food provided did not meet the ordered puree texture. The speech therapist and registered dietitian also verified that the resident was to receive only puree consistency foods and honey thick liquids due to the risk of aspiration. The facility's policy defined puree as smooth and lump-free, which was not followed in this instance.