Failure to Provide Mechanically Soft Diet as Ordered
Penalty
Summary
Resident #2, a male with type 2 diabetes mellitus and recent dental extractions resulting in the removal of seven teeth, was admitted to the facility and had a care plan specifying a mechanically soft, low concentrated sweets diet. Despite this, observations revealed that the resident was served a whole sandwich, which he was unable to eat, and there was no meal ticket present on his tray. Interviews with staff indicated confusion and lack of communication regarding the resident's dietary needs, with some staff being verbally informed of the required diet while others were unaware of any changes. Record reviews showed that the kitchen had documentation indicating a regular diet for the resident, not the mechanically soft diet as specified in the care plan. Further investigation revealed that the process for updating dietary information involved multiple steps, including updating the care plan, sending information to the kitchen, and providing meal slips. However, the dietary manager's absence and unclear communication led to the kitchen not receiving the updated meal information. The facility's policy required special care needs to be communicated through various mechanisms, but in this case, the failure to provide the correct food texture resulted in the resident not receiving food in a form he could eat, as required by his care plan.