Failure to Provide Prescribed Diet Consistencies to Residents
Penalty
Summary
The facility failed to provide two residents with their prescribed diets in the correct consistency during a lunch observation. Both residents were documented as requiring mechanical soft, ground meat diets due to risks such as choking, swallowing difficulties, aspiration, weight loss/gain, and dehydration. However, during the meal service, one resident received cubed chicken parmesan instead of ground meat, and the other received meat in chunks rather than ground, as specified in their dietary orders. These discrepancies were directly observed by the surveyor, who also confirmed the dietary requirements by reviewing the residents' tray tickets and medical records. When the issue was brought to the attention of staff present in the dining room, it was acknowledged that the meat was not prepared as ordered, with staff stating that this was the usual practice. The Food Service Director and the cook both confirmed that the meats should have been ground according to the residents' dietary needs. The deficiency was further discussed with facility leadership, confirming that the prescribed diet consistencies were not provided as required.