Failure to Provide Diet in Appropriate Form for Resident with Dysphagia
Penalty
Summary
A resident with diagnoses including Alzheimer's, underweight status, blindness, left hand contracture, and dysphagia was admitted to the facility and required a specialized diet. Dietary notes indicated that the resident's intake was low and that she was on a mechanical soft diet with pureed meat and fortified foods. On one occasion, the Infection Preventionist observed the resident spitting out vegetables and carbohydrates, and subsequently downgraded her diet to all pureed textures for swallowing safety. The physician and responsible party were notified, and the charge nurse and dietary staff were informed of the change. Physician orders were updated to reflect a fortified, pureed diet. Despite the updated diet order, the resident continued to receive the previous diet of pureed meats only for 33 days, as the change was not communicated to the Registered Dietitian. During an observation, the resident was seen eating pureed food with her hands and had difficulty locating her food, with her tray containing items inconsistent with her dislikes and dietary needs. The Registered Dietitian confirmed that the resident had been receiving the discontinued diet and updated the order for dietary staff after being made aware of the issue.