Failure to Provide Prescribed Diet Texture to Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of protein-calorie malnutrition, hypertension, depression, and bipolar disorder was not provided with the prescribed regular ground diet. Instead, the resident was served a pureed meal, despite the meal ticket indicating the need for a regular ground texture. The resident expressed dissatisfaction with receiving pureed foods, stating that he did not want to eat when served the incorrect texture. Observations confirmed that the resident was given a pureed meal, and staff interviews revealed that the error was due to a failure to verify the correct food texture as indicated on the meal ticket. Multiple staff members, including Central Supply, the RD, the Dietary Manager, and the DON, acknowledged that the resident should have received the regular ground diet as prescribed. The process for meal verification involved several staff, but the error was not caught before the meal was served. The facility's policy required diets to be determined according to residents' needs and preferences, but this was not followed in this instance, resulting in the resident receiving the wrong food consistency.