Failure to Provide Ordered Oral Gratification Diet to Dependent Resident
Penalty
Summary
A resident with diagnoses including muscle weakness, dysphagia, metabolic encephalopathy, and dementia was admitted to the facility and assessed as having severely impaired cognition. The resident required substantial to total assistance with activities of daily living, including oral hygiene and eating. Physician orders were in place for an oral gratification diet with pureed texture and honey consistency fluids, intended to be provided three times daily. From June 1 to June 4, 2025, facility documentation and interviews confirmed that the resident was not assisted with meals during mealtimes as ordered. The Director of Nursing acknowledged that the resident did not receive the prescribed oral gratification diet during this period. Facility policies required that residents receive appropriate care and assistance with meals, but these were not followed for the resident in question.