Failure to Provide Prescribed Pureed Diet to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered pureed diet and nectar thickened liquids was served a mechanically altered meal instead of the prescribed pureed texture. The resident, who had a history of stroke, muscle wasting, dysphagia, non-traumatic brain dysfunction, Alzheimer’s, aphasia, and severe cognitive impairment, was observed coughing after consuming the incorrect food texture. Her meal ticket clearly indicated the need for a pureed diet, but her plate contained chopped carrots, mashed potatoes, and cut-up chicken, which did not meet her dietary requirements. Nursing staff, including an RN and the ADON, acknowledged that the resident received the wrong food texture and that the error was not identified before the meal was served. The RN admitted to overlooking the pureed texture requirement on the tray card and stated that she should have returned the tray to the kitchen immediately. The process for checking trays involved both kitchen staff and nurses, but the system failed to prevent the delivery of the incorrect meal. The RN also mentioned that the resident had been refusing her pureed diet, was edentulous, and did not want to wear dentures, but these factors were not adequately addressed in the care plan or during meal service. The facility’s kitchen policy required that Nutrition & Foodservice staff check each resident’s tray card to ensure the correct diet and portion sizes, and that nurses verify trays before serving. However, interviews revealed that trays were sometimes mixed up, and the required in-services and oversight by the Registered Dietitian were lacking at the time of the survey. The absence of proper checks and adherence to dietary orders led to the resident receiving an inappropriate meal, as documented by both staff interviews and direct observation.