Failure to Implement and Communicate Diet Upgrade for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a recommended diet upgrade for a cognitively intact resident was implemented and properly communicated to staff. The resident, who disliked the pureed diet and expressed a preference for regular food, had been evaluated by Speech Therapy, which recommended a mechanical soft/ground texture diet with thin liquids. Despite this, the resident continued to receive inconsistent meals, sometimes receiving mechanical soft and other times pureed, as evidenced by meal tickets and staff observations. The resident voiced dissatisfaction and confusion regarding the diet provided, and staff were also unclear about the correct diet order. Record review and staff interviews revealed that the Speech Language Pathologist (SLP) had documented the diet upgrade in therapy notes, but the order was not updated in the resident's official diet orders. The Director of Nursing (DON) acknowledged that the SLP should have updated the orders if the diet was changed, but stated that the SLP did not communicate the change to nursing or dietary staff. This lack of communication and failure to update the resident's diet order resulted in the resident not consistently receiving the appropriate diet as recommended by therapy.