Failure to Provide Properly Prepared Mechanical Soft Diet Results in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, and dysphagia following a cerebral infarction was not provided with food prepared in accordance with their prescribed mechanical soft diet. The resident's medical records, care plan, and physician orders all indicated the need for a mechanically altered, therapeutic diet, specifically requiring ground meats. Despite these documented requirements, the resident was mistakenly served a hamburger patty, which does not meet the criteria for a mechanical soft diet, resulting in a choking incident. Staff interviews confirmed that the error occurred when the resident received their roommate's meal tray, which did not match the resident's dietary needs. The Registered Dietician clarified that mechanical soft meats are considered ground meats and that a hamburger patty is not appropriate for this diet. The Dietary Manager also confirmed the dietary error and observed the incorrect tray delivery. The incident highlights a failure in ensuring that food provided matched the resident's individualized dietary requirements as documented in their care plan and physician orders.