Failure to Provide Food in Appropriate Form for Residents Needing Modified Diets
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of two residents. Both residents had documented cognitive impairments and required assistance with eating. Care plans and physician orders specified that their meats should be cut into bite-sized pieces to aid in self-feeding and ensure safety. However, during a noon meal service observation, staff cut the cheddarwurst into very large chunks for these residents, rather than the required bite-sized pieces. The dietary manager confirmed that the pieces were not appropriately sized as per the care plans and therapy recommendations. Documentation reviewed included care plans, diet rosters, and therapy communications, all of which indicated the need for cut-up meats. The kitchen's white board listed the residents requiring cut-up meat but did not specify the size or method. The administrator was unable to locate a policy on diet orders, and the dietary manager stated that they relied on nurse instructions and care plans. This lack of clear guidance and failure to follow individualized dietary instructions resulted in the deficiency.