Failure to Provide Prescribed Pureed Diet to Resident with Dysphagia
Penalty
Summary
A resident with a history of dysphagia, Huntington's Disease, adult failure to thrive, severe protein-calorie malnutrition, and previous choking incidents was admitted to the facility with physician orders for a regular diet with puree texture and nectar consistency liquids. The resident's care plan, nutrition assessment, and CNA Kardex all specified the need for a pureed diet. Despite these documented requirements, the resident was observed being provided with a peanut butter and jelly sandwich, which is not appropriate for a pureed diet, after requesting food at the nurses' station. The Assistant Director of Nursing (ADON) called the kitchen for a sandwich without reviewing the resident's diet orders, and the kitchen staff sent up the sandwich without verifying the prescribed diet. The sandwich was left at the resident's bedside without supervision. Multiple staff interviews confirmed that the resident should not have received a peanut butter and jelly sandwich due to the risk of choking, given the resident's dietary restrictions and history. The speech therapist, nurses, CNA, Food Service Director, and DON all acknowledged that the resident was on a pureed diet and that the sandwich was inappropriate and potentially dangerous. The incident demonstrated a failure by both nursing and dietary staff to verify and follow the resident's prescribed diet, as well as a lack of communication and adherence to the care plan and physician orders.