Failure to Provide Pureed Food as Ordered for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered Level 1/pureed diet due to dysphagia was served a banana that was only cut in half and left in the peel, rather than being pureed as required by the resident's diet order and meal ticket. The facility's own Diet/Texture Conversion Chart and national guidelines specify that foods on a pureed diet must be homogenous, cohesive, and pudding-like, with fresh bananas to be served well-mashed or pureed. During meal preparation, the surveyor observed that while other items on the resident's tray were properly pureed, the banana was not, and this was confirmed by both the Food Service Manager and a CNA, who acknowledged the error. The resident's care plan and physician orders documented the need for a pureed diet with honey-thickened liquids due to swallowing difficulties, edentulism, and nutritional risk. Despite these documented needs, the resident was served a banana in a form inconsistent with the prescribed diet. The surveyor observed the uneaten banana on the resident's bedside table after the meal, indicating it was not consumed. The deficiency was discussed with facility leadership during the survey process.