Failure to Provide Prescribed Pureed Diet Results in Dietary Deficiency
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and a history of traumatic subdural hemorrhage, who was prescribed a regular pureed diet with nectar/mildly thick liquids due to dysphagia, was served mashed potatoes containing large chunks of potato during a dinner meal. The resident's care plan and physician orders specified a pureed diet to mitigate the risk of aspiration and choking, and these requirements were documented in the resident's records. Despite these clear dietary orders, the meal provided did not meet the prescribed texture modification, resulting in a potential risk for aspiration. Staff interviews revealed that licensed nurses were responsible for checking meal trays for correct diets before distribution by CNAs. On the day of the incident, a licensed nurse identified the presence of potato chunks in the resident's mashed potatoes and intervened to remove the food from the resident's mouth to prevent choking. The nurse reported the incident to the Dietary Manager and the Assistant Director of Nursing, and a correct meal tray was subsequently provided. The Dietary Manager confirmed that the cook responsible for preparing the meal was unaware of the resident's dietary requirements and did not follow facility policy, as the meal ticket was missing. The facility's policy on therapeutic diets, which requires adherence to physician-ordered texture modifications, was not followed in this instance. The Registered Dietitian and Dietary Manager both confirmed that the resident should have received a pureed meal and that the risk of serving food with chunks was choking. The incident was corroborated by multiple staff interviews and a review of the facility's menus and dietary orders, all of which indicated that the resident did not receive the prescribed diet consistency.