Failure to Provide Physician-Ordered Diets to Residents
Penalty
Summary
The facility failed to provide physician-ordered diets to four residents with significant medical conditions, including severe cognitive impairment, diabetes, stroke, and swallowing difficulties. Despite clear care plans and physician orders specifying specialized diets such as pureed, mechanical soft, and carbohydrate-controlled diets, these residents consistently received regular meals identical to those served to other residents. Observations revealed that meal tickets indicating dietary requirements were missing or not updated, and staff were unaware of the specific dietary needs of the residents. For example, one resident with a pureed diet order due to high aspiration risk was observed receiving and struggling to eat regular food items like toast and cereal. Staff, including CNAs and the DON, were unaware of the resident's dietary restrictions, and the dietary manager admitted the resident was not listed on the special diet roster. Other residents with orders for mechanical soft diets also received regular meals, such as noodles and beef, which were not appropriately modified according to their dietary needs. The dietary manager and cook acknowledged that the food provided did not meet the required texture modifications and that the list of residents on special diets was outdated. Interviews with residents confirmed that they routinely received the same food as everyone else, regardless of their prescribed diets. Staff interviews further revealed a lack of communication and understanding regarding residents' dietary orders. The facility's own policy required individualized diet modifications based on physician and speech-language pathologist recommendations, but these procedures were not followed, resulting in the failure to provide appropriate diets as ordered.