Failure to Provide Pureed Food at Correct Texture for Resident on Mechanically Altered Diet
Penalty
Summary
A deficiency occurred when a resident with dementia, pulmonary embolism, and heart disease, who was on a mechanically altered diet requiring pureed food and honey thickened fluids, was served pureed zucchini that did not meet the required texture. During meal preparation, the cook failed to add thickener to the zucchini, resulting in a thin, liquid consistency that did not hold its shape, contrary to the facility's policy and recipe, which specified a pudding or mashed potato-like texture. The Dietary Manager (DM) and Administrator (ADMN) identified the issue during a spot check, and the DM subsequently re-pureed the food to the correct consistency. Interviews revealed that the cook was trained by a previous Dietary Manager and admitted to being nervous and not following the recipe. The DM stated that kitchen staff are responsible for following recipes and ensuring correct food texture, and that she monitors compliance through spot checks. The Registered Nurse (RRN) confirmed that the DM is responsible for ensuring pureed food is served at the correct texture and noted that the failure was due to lack of education or need for reeducation among staff. Facility policy and the specific recipe for pureed zucchini both emphasized the importance of achieving the correct consistency for resident safety.