Failure to Provide Properly Prepared Pureed Diet
Penalty
Summary
The facility failed to ensure that food prepared for a resident on a pureed diet was of the appropriate consistency as required by the resident's care plan and physician's orders. Observations revealed that the pureed meals served, including soft beef tacos, brownies, steak fingers, and mixed vegetables, were not of a smooth or pudding-like consistency, but instead had a coarse or chunky texture. Staff interviews confirmed that the food did not meet the required standards for pureed diets, and that the consistency was not physically tested before serving. The dietary manager and other staff acknowledged that menus and recipes, which specified the need for a smooth, creamy texture, were not followed for the preparation of pureed foods. The resident involved had severe cognitive impairment, was dependent for activities of daily living including feeding, and had a history of ataxia, dementia, malnutrition, and risk for aspiration. The care plan and physician's orders specified a pureed diet with thin liquids, and the facility's policy required adherence to therapeutic diet recipes and consistency checks. Despite these requirements, the resident was served food that did not meet the prescribed texture, as confirmed by both staff and administrative personnel during interviews and direct observation.