Resident Served Incorrect Food Texture Despite Pureed Diet Order
Penalty
Summary
A deficiency occurred when a resident with a physician's order for a pureed diet was served a mechanically chopped breakfast meal. The resident, who had diagnoses including Progressive Supranuclear Palsy, secondary Parkinsonism, and dysphagia, required a pureed diet due to swallowing difficulties. Documentation confirmed the diet order for pureed texture and thin liquids, and the care plan included interventions to ensure the resident received the appropriate diet and assistance as needed. On the morning of the observed deficiency, the resident was served a breakfast containing grits, scrambled eggs, and sausage, with the eggs and sausage appearing to be mechanically chopped rather than pureed. The nursing assistant assigned to the resident acknowledged that the sausage was not pureed and stated she had intended to replace it but did not do so after the resident indicated he did not want sausage. The nursing assistant did not report the dietary error to the Resource Nurse as initially claimed, later admitting she had not reported it at all. Interviews with dietary and nursing staff revealed that the resident's diet order was entered into the computer system and tray tickets were used to guide meal preparation. The Dietary Manager could not explain how the mechanically chopped food was served instead of pureed, and the staff member responsible for preparing the food stated she was unaware of the error. Both the Director of Nursing and the Administrator confirmed their expectation that residents receive food in the correct consistency as ordered.