Failure to Provide Prescribed Pureed Diet for Resident with Dysphagia
Penalty
Summary
A resident with a history of dysphagia had a physician's order for a regular/liberalized dysphagia advanced texture diet, specifically requiring pureed fruits and vegetables. The resident's care plan identified them as being at nutritional risk due to dysphagia, with interventions in place to provide a dysphagia diet as ordered. Despite these orders and care plan interventions, observations on two separate occasions revealed that the resident was served whole sliced pears and cut pieces of watermelon, rather than pureed fruits as required. Staff interviews confirmed that these items were not pureed and did not meet the dietary requirements specified for the resident. Further review of the resident's speech therapy discharge summary confirmed the ongoing need for pureed fruits and vegetables due to swallowing issues. The facility's own Diet and Nutrition Care Manual and policy on therapeutic diet orders also specified that foods for residents on a dysphagia puree diet must be provided in pureed form. Both dietary and nursing staff were responsible for ensuring therapeutic diets were provided as prescribed, but failed to do so in this instance, resulting in the resident not receiving the appropriate diet texture as ordered.