Failure to Provide Physician-Ordered Diet Textures to Two Residents
Penalty
Summary
Two residents did not receive food prepared in the form required by their physician-ordered diets. One resident, who had a physician order for a pureed diet due to diagnoses including Alzheimer's disease, malnutrition, anorexia, and vitamin deficiency, was served a banana that was mashed with chunks rather than being fully pureed to a smooth, pudding-like consistency. Multiple staff, including a CNA, the cook, the Certified Dietary Manager (CDM), and the Registered Dietician (RD), confirmed that the banana was not pureed as required and that the resident was not served the correct texture as ordered. The resident's records and assessments indicated significant cognitive impairment, and the staff acknowledged that serving food with the wrong texture could pose a risk to the resident. Another resident, with a physician order for a bland diet with regular texture and thin liquids, was served minced meat instead of the regular textured meat as ordered. Observations and interviews with a CNA, an LVN, and the Dietary Manager confirmed that the meat was not of regular texture and that the resident did not receive the diet texture as ordered by the physician. The Dietary Manager and DON both stated that the expectation was for staff to check each food plate to ensure residents are served the correct diet before food is delivered. Review of job descriptions and facility policies showed that staff are expected to prepare and serve food according to physician orders and resident needs, and that therapeutic diets must be prescribed and followed as specified. The facility's recipe for pureed fruit and policy on therapeutic diets both emphasized the importance of preparing food to the correct texture and consistency as ordered by the physician.