Failure to Provide Proper Pureed Diet Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for residents requiring pureed diets. One resident with severe cognitive impairment, multiple diagnoses including dysphagia, and a care plan specifying a pureed diet with nectar thickened liquids, was observed with pre-packaged snacks on their overbed table that were not consistent with their prescribed diet. The Speech Language Pathologist (SLP) confirmed that these snacks were not appropriate for a pureed diet and identified risks associated with not following the prescribed diet. Another resident, cognitively intact but with diagnoses including dysphagia and a care plan for a pureed, nectar thickened, renal diet, was observed with oatmeal that contained lumps and was not smooth, contrary to the requirements for a pureed diet. The SLP reviewed a photo of the oatmeal and confirmed it did not meet the pureed diet standard. The resident was unable to be interviewed during the observation as they fell asleep during the meal. Additionally, during a kitchen observation, pureed foods such as seasoned spinach and chorizo and cheddar quiche were found to have irregular textures, including lumps and fibrous strands, and did not meet the IDDSI standard for pureed foods. The Food Service Director acknowledged these findings. The facility's policy requires pureed foods to be smooth and require no chewing, but this standard was not met for at least two residents and in the main kitchen, potentially affecting 22 residents.