Failure to Provide Food and Liquids in Prescribed Form for Residents with Special Dietary Needs
Penalty
Summary
The facility failed to provide food and liquids in the prescribed form for two residents with specific dietary needs. One resident, with a history of hypertension, heart failure, and chronic kidney disease, had physician orders and care plans specifying a minced and moist texture diet with thin liquids due to aspiration risk. Despite this, the resident was observed receiving a regular tropical fruit cup instead of the required minced fruit cup. The Registered Dietitian confirmed that the regular fruit cup did not meet the required texture, and the Food Service Director acknowledged that dietary staff had not received documented in-service training on the new diet textures, nor was there a policy in place regarding diet textures and consistencies. Another resident, diagnosed with chronic obstructive pulmonary disease, schizoaffective disorder, and heart disease, had orders for a regular diet with nectar-thick liquids due to swallowing difficulties. This resident was observed with a lunch tray containing thickened liquids but also had access to a pitcher of non-thickened ice water, which was provided by a Certified Nurse Aide (CNA) who was unaware of the resident's dietary restrictions. Interviews revealed that CNAs did not have clear access to or knowledge of residents' diet orders, and the LPN and Director of Nursing confirmed that the resident should not have received regular water. The dietician also stated that the resident should not have received regular water.