Failure to Provide Foods in Appropriate Texture for Residents with Swallowing Disorders
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents with swallowing difficulties and other nutritional concerns. Four out of five sampled residents were affected, including individuals with diagnoses such as dysphagia, cerebral infarction, malnutrition, and muscle weakness. In one instance, a resident with severe cognitive impairment and a physician-ordered mechanically altered diet was served and consumed a whole hot dog, which was not prepared according to her dietary requirements. Staff involved did not verify the appropriateness of the food texture, and the kitchen did not prepare the hot dog in the required ground form, despite the menu specifying a ground hot dog for those on mechanically altered diets. Additionally, staff provided this resident with snacks such as potato chips and Goldfish crackers, which were not suitable for her prescribed diet. Other residents on pureed diets were observed receiving foods that did not meet the required texture standards. One resident received soup containing whole grains of rice and intact corn kernels, and another was served pureed foods that were lumpy and not homogenous, as required for a pureed diet. Observations in the kitchen confirmed that some pureed foods, such as baked ham, were not consistently smooth and contained small lumps. Staff interviews revealed a lack of understanding regarding the differences between diet textures and the importance of matching meal tickets and physician orders. The facility's policies and professional standards, including those from the National Dysphagia Diet Task Force and the International Dysphagia Diet Standardization Initiative, were not consistently followed. There were discrepancies between diet orders in the electronic medical record and the meal ticket software, leading to confusion among staff. Staff members were not always aware of the specific dietary needs of residents or the consequences of serving inappropriate food textures, resulting in the provision of foods that posed a risk to residents with swallowing difficulties.