Failure to Provide Diet Texture as Ordered for Resident with Dysphagia
Penalty
Summary
Facility staff failed to provide a resident with food prepared in a form designed to meet her individual dietary needs, as ordered by her medical provider. The resident, who had diagnoses including dysphagia, dementia, and a history of falls, was assessed as severely cognitively impaired and required a mechanical soft diet with ground meats. Despite clear orders and care plan interventions specifying a mechanical soft diet, the resident was observed receiving a regular pork chop cut into large strips and a piece of pie with crust, instead of ground meat and crustless pie as indicated on her tray ticket. Staff present at the time acknowledged the discrepancy, and the dietary manager confirmed the meal did not meet the ordered diet texture. Further interviews with staff and review of facility documentation revealed ongoing confusion regarding the resident's diet, partly due to conflicting preferences from the resident's family. The tray ticket system defaulted to ground meats for mechanical soft diets, but nursing staff were instructed to chop meat in an attempt to liberalize the diet per family wishes. The speech therapist and multiple CNAs confirmed the resident should have received ground meats for safety. Facility policy required meals to be provided as ordered by the healthcare provider, but this was not followed in this instance.