Failure to Provide Ordered Pureed Diet Texture
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, dysphagia, and multiple diagnoses including Alzheimer's disease and gastro-esophageal reflux was not provided with the ordered pureed diet texture. The resident's care plan and physician orders specified a regular diet with pureed texture and thin liquids, and a recent speech language pathology evaluation confirmed the need to maintain this diet due to safety concerns. During a meal observation, the resident was served a full piece of pork loin, which she was unable to chew, instead of the required pureed texture. Staff replaced the pork loin with minced meat after noticing the issue, and the resident was then able to eat independently. Interviews with dietary and nursing staff revealed reliance on meal tickets to determine diet orders, but also indicated inconsistencies in the availability and serving of pureed foods. The dietary aide confirmed that pureed pork was not available that day and that only mechanically cut-up pork was served, including to the resident in question. Staff interviews further indicated that while there were systems in place, such as spreadsheets and meal tickets, to communicate diet orders, there were lapses in ensuring the correct texture was always provided. Facility policies required meals to be assembled according to individualized diet orders and for nursing staff to verify meal accuracy, but these procedures were not followed in this instance.