Failure to Provide Diet-Appropriate Food Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food in a form consistent with a dysphagia advanced diet for a resident with significant cognitive impairment and multiple diagnoses, including Parkinson's disease, dementia, and Alzheimer's disease. The resident had physician orders specifying a regular diet with dysphagia advanced texture, thin liquids, and specific fortified foods. The care plan included interventions to observe for signs of aspiration or dysphagia and to provide meals according to the diet order. Despite these orders and interventions, the resident was served whole Brussel sprouts instead of the required chopped Brussel sprouts, as indicated on both the facility's diet guide sheet and the resident's diet slip. During lunch, a family member feeding the resident noticed the whole Brussel sprouts and questioned staff about the appropriateness of the food, expressing difficulty in cutting the vegetable. Staff confirmed that the resident should have received chopped Brussel sprouts. Facility policy required that all meals be assembled according to individualized diet orders and that nursing staff verify meal accuracy before delivery. This deficiency was identified during a survey and affected one of six residents on a dysphagia advanced diet.