Failure to Provide Properly Prepared Pureed Foods and Thickened Liquids
Penalty
Summary
Surveyors found that the facility failed to provide pureed foods and thickened liquids in the appropriate consistency for several residents with dysphagia and other conditions requiring mechanically altered diets. Observations revealed that three residents on Dysphagia Puree texture diets were served pureed foods that were lumpy and not of a homogenous, pudding-like consistency as required by facility policy and the National Dysphagia Diet guidelines. Specifically, pureed rice and meat were observed to be lumpy or contain sand-like particles, and pureed bread, while tasting smooth, appeared lumpy. The kitchen manager acknowledged that the pureed meat could be smoother and that the rice did not appear to be of a uniform texture. These issues were confirmed through direct observation, tasting, and photographic evidence. Additionally, a resident with an order for nectar thickened fluids was observed with thin coffee and regular consistency water on their meal tray, despite the meal ticket specifying nectar thick fluids. Staff confirmed that the water was not thickened and that the coffee was too thin, with thickener not fully mixed, resulting in a lump of unmixed powder at the bottom of the cup. These deficiencies were identified through interviews with staff, review of medical records and diet orders, and direct observation of meal service, affecting residents with severe cognitive impairment and significant medical needs related to swallowing and nutrition.