Failure to Provide Ordered Therapeutic Diet and Meal Assistance
Penalty
Summary
A resident with a history of stroke, diabetes, non-Alzheimer's disease, and malnutrition, who was cognitively impaired and required supervision while eating, did not receive the therapeutic diet ordered by her healthcare provider. The resident was supposed to be on a regular, ground diet with specific instructions for meal assistance and positioning due to swallowing problems. On the observed date, the resident was found lying in bed at a 30-degree angle, unable to reach all the food on her tray, and was served a whole sandwich instead of ground meat, contrary to her dietary order. Staff interviews revealed that the LVN was unaware of the resident's correct diet and had to check the order, while the ADON confirmed the resident should not have received a whole sandwich due to choking risk. The CNA who delivered the tray admitted to not checking the tray for accuracy or assisting the resident to sit up, citing being rushed. The dietician confirmed the resident was on a ground diet and that the kitchen and nursing staff were responsible for verifying the tray contents. The DON also acknowledged that the resident was not properly supervised and was at risk for choking if served the wrong diet. Facility policy required that all dining services staff follow the prescribed diet orders and ensure proper food texture and resident positioning. However, the failure to provide the correct diet, ensure proper tray delivery, and supervise the resident during meals led to the deficiency, as the resident did not receive the ordered therapeutic meal and was not assisted as required.