Failure to Provide Physician-Ordered Pureed Diet to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered pureed diet due to dysphagia was served a mechanical soft lunch tray instead of the required pureed consistency. The resident's medical record indicated a history of difficulty swallowing, severe cognitive impairment, and a care plan specifying the need for a pureed diet to prevent choking and aspiration. Despite these documented needs, the resident was provided with the incorrect food texture during a meal service. The error originated in the kitchen, where the dietary aide, feeling rushed, misread the meal ticket and placed a mechanical soft plate on the tray instead of the pureed plate. The tray was then delivered to the resident's room by a CNA, who did not notice the inconsistency and began feeding the resident. The nurse was not present during the initial tray delivery and did not check the tray before feeding commenced. The CNA gave the resident one bite and attempted a second before the resident refused further intake by closing her lips. The mistake was identified when the nurse entered the room and recognized the resident was being fed the wrong diet. The tray was immediately removed, and the resident was assessed for any signs of aspiration or choking, with no adverse symptoms observed at that time. The incident was reported to supervisory staff, and the resident's physician and family were notified. The deficiency was attributed to failures in both dietary and nursing staff to verify the correct diet consistency before serving and feeding the resident.