Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
Two residents with severe cognitive impairment and a history of swallowing difficulties were not provided with mechanically altered diets as ordered by their physicians. Both residents had physician orders and care plans specifying an L3/Advanced texture diet, which requires foods to be soft, moist, and cut into bite-sized pieces less than one inch. During meal service, both residents received cubed pork loin that was hard and larger than one inch, as well as firm broccoli spears, instead of the required ground meat and soft, mashed broccoli. Tray cards for both residents indicated the correct diet, but the meals served did not comply with these orders. Staff interviews revealed that the blender used to prepare mechanically altered foods was broken, and there was confusion among dietary staff regarding the use of available kitchen equipment. The Dietary Manager confirmed that the food served did not meet the required texture and size, and the Director of Nursing acknowledged that the diet cards should have been followed, especially given the residents' severe dementia and eating difficulties. The Registered Dietitian also confirmed the requirements for the L3/Advanced diet. These failures resulted in the residents not receiving the prescribed diet texture and consistency.