Failure to Provide Prescribed Altered Texture Diets for Residents with Dysphagia
Penalty
Summary
The facility failed to provide altered texture diets as prescribed by physicians for multiple residents with dysphagia. Specifically, six residents who were ordered a dysphagia advanced texture diet received round slices of carrots that exceeded the recommended size for their diet, rather than the required chopped carrots no larger than ½-inch by ½-inch pieces. This was observed during meal service, and the meal tickets for these residents clearly indicated the need for chopped carrots, but the kitchen staff served sliced carrots instead. Facility policies required that residents with swallowing difficulties receive appropriate diet modifications, and the master menu diet guide sheets specified the correct form and size for vegetables on dysphagia advanced diets. Despite these guidelines, the kitchen staff did not follow the prescribed diet texture, and the dietary manager confirmed that the carrots served did not meet the required specifications. The speech language pathologist also confirmed that no changes had been made to the menu guidance and that the expectation was for kitchen staff to serve food in the appropriate texture as outlined by the International Dysphagia Diet Standardization Initiative. This failure to provide food in the prescribed form placed an additional fourteen residents with similar dietary needs at high risk, resulting in an Immediate Jeopardy situation. The deficiency was identified through observations, record reviews, and staff interviews, which confirmed that the facility did not follow its own policies or physician orders regarding diet texture for residents with dysphagia.