Failure to Provide Mechanically Altered Diet as Ordered
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia was admitted to the facility and had a physician's order for a mechanical soft diet. The resident's care plan identified an increased nutrition and hydration risk related to the need for a mechanically altered diet, with interventions specifying that the diet and supplements should be provided as ordered. During a lunch meal observation, the resident was served two whole boneless chicken breasts, which did not meet the requirements of a mechanical soft diet as ordered by the physician and indicated on the meal ticket. The error was identified before the resident began eating, and the meal was removed after confirmation by the administrator that whole chicken breasts were not mechanically soft. Staff interviews revealed that the nurse aide who set up the tray did not notice the discrepancy, and the dietary manager was unsure why the correct meal was not provided. The registered dietitian and speech therapist both confirmed that the resident should have received the mechanically altered diet as ordered, and that whole chicken breasts were not appropriate for this diet texture.