Failure to Provide Prescribed Therapeutic Diet to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with severe dysphagia and a physician-ordered minced and moist diet received meals consistent with their prescribed dietary requirements. Despite clear documentation in the resident's records, including a speech therapy plan recommending pureed consistency food and a physician's order for a minced and moist texture diet, the resident was served toasted bread on their lunch tray. The responsible party reported repeated notifications to staff about the resident's inability to safely consume bread, yet bread continued to be provided. The dietary service supervisor acknowledged the error, stating the bread was likely placed on the tray by accident, and recognized the risk of choking associated with this mistake. Further review revealed that the facility's policies required both dietary and nursing staff to check trays for correct diet and texture before serving meals to residents. However, interviews with staff indicated that these checks were not properly conducted, resulting in the resident being served inappropriate food items. The director of nursing confirmed that failure to check trays could lead to residents receiving the wrong diet, which in this case, exposed the resident to potential harm due to their swallowing difficulties.