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F0805
D

Failure to Provide Prescribed Mechanically Altered Diet

West Des Moines, Iowa Survey Completed on 05-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with significant cognitive impairment, a history of weight loss, and multiple diagnoses including GERD and seizure disorder, was not provided with the prescribed mechanically altered diet. The resident's care plan and diet card specified a mechanically soft diet with ground meats, but during a direct observation, the resident was served a regular diet soup containing large, tough chunks of beef and vegetables. Staff feeding the resident noticed the inconsistency, as the meat could not be easily cut or mashed, and confirmed it was not appropriate for the resident's ordered diet. Interviews with staff revealed that dietary staff were responsible for plating food according to diet cards, while CNAs served the food. Both the CNA and dietary manager confirmed the meal served did not meet the resident's dietary requirements. The dietary manager attributed the error to confusion stemming from a previous hospice provider's order, which had allowed for pleasure feedings of normal textured foods, whereas the current order required only mechanically altered foods. Facility policy required mechanically soft diets to include moist, ground meats and soft foods, which was not followed in this instance.

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