Failure to Provide Properly Prepared Pureed Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered pureed diet consistently received food prepared in the correct form to meet her individual needs. The resident, an elderly female with severe dementia, dysphagia, and protein-calorie malnutrition, was dependent on staff for most activities of daily living and required a pureed diet to reduce the risk of choking and aspiration. Observations revealed that her pureed meals were not prepared according to facility recipes or dietary guidelines, resulting in food that was watery, grainy, lumpy, and sometimes sweet due to the inappropriate use of apple juice as a liquid for pureeing eggs and sausage. Additionally, regular oatmeal, which contained lumps, was served instead of a properly pureed version, and pureed bread was omitted from her meal despite being available for other residents. Interviews with dietary staff indicated inconsistent and incorrect training regarding the preparation of pureed foods. One dietary aide reported being trained to use water or apple juice as the liquid for pureeing, while another stated she had not received training at this facility and relied on practices from a previous job. The registered dietitian confirmed that the correct consistency for pureed food should be smooth, thick, and free of lumps, and that apple juice and water were not appropriate liquids for pureeing eggs or sausage. Facility recipes and policies also specified the use of milk, broth, or gravy as appropriate liquids and emphasized the importance of following recipes to ensure proper texture and nutritional value. Further observations documented that the resident's pureed food was sometimes delivered to the wrong tray, and that the texture of the food served remained incorrect even after being remade. Staff interviews consistently acknowledged that food not prepared to the correct consistency could pose a choking hazard. Despite in-service trainings and written policies outlining the correct procedures for preparing pureed diets, the facility did not ensure that staff consistently followed these guidelines, resulting in the resident receiving food that did not meet her prescribed dietary needs.