Failure to Provide Food in Physician-Ordered Texture
Penalty
Summary
The facility failed to provide food in the appropriate texture as ordered by physicians for four residents who required mechanical soft diets. Despite having active orders and care plans specifying the need for mechanical soft or chopped food textures, these residents were served pieces of cauliflower that exceeded the recommended size for their dietary needs. In one instance, a resident also did not receive a prescribed PB&J sandwich with their meal. These actions were observed during meal service and were not in accordance with the dietary orders documented in the residents' records. The residents affected had significant medical histories, including conditions such as hemiplegia, dementia, Parkinson's disease, chronic obstructive pulmonary disease, and dysphagia. Their care plans and physician orders clearly indicated the need for modified diets, such as mechanical soft textures and specific food items to be provided at certain meals. The facility's own diet spreadsheet and policy required that food be prepared and served according to these orders, and that a tray identification system be used to ensure accuracy. Additional documentation from resident council forms indicated ongoing concerns about meal service, including reports that meal tickets were not being read properly, residents were receiving items they did not like, and portion sizes were inconsistent. These issues suggest that the facility's processes for preparing and serving meals according to individual dietary needs were not consistently followed, resulting in the observed deficiencies.