Failure to Provide Prescribed Puree Diet to Resident with Dysphagia
Penalty
Summary
The facility failed to provide the correct prescribed diet to a resident with a documented swallowing problem and edentulism. Despite physician orders and care plan interventions specifying a puree/dysphagia puree diet with mechanical soft and pureed meats, the resident was observed receiving and served regular food items such as chicken on the bone, a roll, whole waffles, and bacon, which were not consistent with her dietary requirements. The resident reported difficulty consuming these foods and stated that the kitchen sometimes failed to provide the prescribed items like magic cup and mighty shake, as indicated on her meal ticket. Staff interviews confirmed that the resident was served a regular diet instead of the required puree diet, and the Director of Nursing acknowledged that the correct diet was not provided. The resident's medical record indicated a diagnosis of Alzheimer's Disease, a swallowing problem related to dysphagia, and edentulism, all of which necessitated a specialized diet to prevent choking and ensure adequate nutrition. Observations and interviews revealed that the facility's food and nutrition services policy, which requires inspection of food trays and prompt correction of errors, was not followed. The resident's care plan and physician orders were not adhered to, resulting in the resident being served inappropriate meals on multiple occasions.