Failure to Provide Prescribed Pureed Diets to Residents
Penalty
Summary
The facility failed to provide food in the prescribed pureed consistency for four residents who required pureed diets due to medical conditions such as dysphagia, dementia, cerebral infarction, and profound intellectual disabilities. Each resident had physician orders and care plans specifying a pureed diet, and their meal tickets reflected this requirement. However, during meal observations, all four residents were served food with a mechanical soft consistency rather than pureed, and in one case, a regular consistency dessert was also provided. Multiple staff interviews revealed a lack of proper training and oversight in preparing and verifying the correct food consistency. The cook responsible for preparing the pureed meals admitted to not being trained and not following a recipe, especially on the day in question when he was rushing. Dietary supervisors and managers were either absent, did not check the trays, or were unaware of the consistency issue before the meals were served. Nursing staff, including LVNs and CNAs, also failed to identify or question the incorrect consistency, often assuming that prior checks by other staff were sufficient. Facility policies and standardized recipes were in place, specifying the required consistency for pureed diets, but these were not followed. Interviews with the regional dietician, dietary supervisor, and administrative staff confirmed that the expected procedures for preparing and verifying pureed diets were not implemented. The lack of adherence to dietary orders and failure to ensure proper food consistency directly led to the deficiency, as residents with significant swallowing disorders were not provided with food in a form they could safely consume.