Failure to Provide Mechanically Altered Diet as Prescribed
Penalty
Summary
Facility staff failed to provide food in a form designed to meet the individual needs of a resident who was prescribed a mechanically altered, soft and bite-sized pleasure diet due to multiple medical conditions, including dysphagia, oropharyngeal disease, and loss of teeth. The resident, who received gastrostomy tube feedings for nutrition and required maximum assistance with eating, was observed with a lunch tray containing roast beef chunks that were not mechanically altered to the prescribed bite-sized texture. The assigned CNA was preparing to feed the resident but was unable to confirm if the food was appropriate for the resident's diet. Upon further review, the speech pathologist assessed the tray and determined that the roast beef pieces exceeded the required bite-sized specification, stating that this was unsafe for the resident. The dietician was also unsure if the food met the prescribed requirements. The Director of Food and Nutrition later acknowledged that the resident had been served a regular diet instead of the ordered bite-sized diet, confirming an error in meal preparation and delivery for this resident.