Failure to Provide Ordered Pureed Diet to Resident with Dysphagia
Penalty
Summary
A severely cognitively impaired resident with diagnoses including progressive supranuclear palsy, secondary parkinsonism, and dysphagia was admitted with a physician's order for a pureed diet, thin liquids, and double protein. The resident's care plan noted a risk for injury related to his medical conditions, a history of pocketing food, and a tendency to refuse staff assistance during meals. On the observed morning, the resident was found eating from a bowl containing grits, scrambled eggs, and sausage, with the eggs and sausage appearing to be of mechanically chopped texture rather than the required pureed consistency. The resident was able to feed himself and was left alone with the meal by the assigned nursing assistant (NA). The NA admitted to placing some of the remaining eggs and sausage into the resident's bowl of grits and leaving it with him, despite knowing the sausage was not pureed as ordered. The NA did not report the dietary error to the Resource Nurse, who was also unaware of the incident until interviewed. The dietary staff confirmed that pureed and mechanically chopped sausages were stored separately and looked different. Both the DON and the Administrator stated their expectation that residents receive the correct food consistency as ordered. The failure to ensure the resident received the prescribed pureed diet and to report the dietary error constituted a deficiency in providing adequate supervision and accident hazard prevention.