Resident Served Incorrect Food Texture Despite Regular Diet Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypertensive heart disease and malignant neoplasm of the colon, who was cognitively intact and able to make decisions, was not provided with the correct diet as ordered. The resident was assessed to require a regular diet with regular texture, and this was documented in the admission record, order summary, and nutritional assessment. Despite these clear orders, the resident was served ground meat, which is intended for a mechanical soft diet, rather than the regular texture diet that was ordered. During mealtime, the resident received a tray with ground meat and expressed confusion and dissatisfaction, stating a preference for regular texture food and questioning whether there had been a change in her diet that she was not informed about. The resident confirmed she had no issues with chewing or swallowing and did not want the ground meat, which she associated with residents who have such difficulties. Staff interviews and observations confirmed that the dietary card indicated a regular diet with regular texture, and both the CNA and Dietary Supervisor acknowledged that the resident had been served the wrong food texture due to a mistake. Further interviews with nursing staff, including an LVN and RN, revealed that all food delivered to residents is supposed to be checked by dietary staff, licensed nurses, and CNAs to ensure it matches the dietary card, including diet type, texture, and allergies. The DON also confirmed that serving a mechanical soft diet to a resident ordered for a regular texture diet was not acceptable and could affect the resident's psychosocial well-being. The facility's policy indicated that therapeutic diets are to be provided according to physician orders and resident preferences.