Failure to Provide Food in Appropriate Texture for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food in a form that met the individual dietary needs of two residents with dysphagia and other medical conditions. For one resident with dysphagia and dementia, a physician's order required a mechanically altered, ground diet. However, observation revealed that the resident was served large pieces of cut meat that were not ground or mechanically soft, as required. Staff interviews confirmed that the meat was only cut with a rocker knife and not processed to the appropriate texture, despite the resident's tray ticket specifying a mechanically soft, ground diet. Another resident, also with dysphagia, dementia, and esophageal stricture, had a physician's order for a pureed diet and was identified as being at nutritional risk and requiring supervision during meals. Despite these orders, the resident was served a regular texture meal and vomited after eating a few bites. The care plan and staff notes confirmed the resident's need for a mechanically altered diet and supervision, which were not provided at the time of the incident.