Failure to Provide Prescribed Therapeutic Diet and Food Texture
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's Disease, dysphagia, chronic respiratory failure, diabetes, and legal blindness, did not receive food prepared in accordance with her prescribed therapeutic diet. The resident's care plan and physician orders specified a mechanically altered, pureed diet with mildly thick liquids, and most of her nutrition was to be provided via G-tube feedings. Despite these orders, the resident was observed receiving regular textured foods, such as scrambled eggs, refried beans, and bread, on her breakfast tray. Staff interviews confirmed that the resident routinely received pleasure trays with regular textured foods, and there was confusion among dietary and nursing staff regarding the existence and appropriateness of orders for these pleasure trays. The facility failed to ensure that food was prepared and served in a form that met the resident's individual needs as outlined in her comprehensive assessment and care plan. Multiple staff members, including CNAs, LVNs, and the dietary manager, acknowledged that the resident required assistance to eat, could not use utensils independently, and should not have been given regular textured foods due to her swallowing difficulties and lack of dentures. The dietary manager and registered dietitian were unaware of any physician order for pleasure trays, and the registered dietitian minimized concerns about the risk of aspiration from the foods provided. Additionally, the resident's responsible representative and several staff members reported that the resident was not consistently supervised during meals, despite her need for assistance and risk of choking or aspiration. Documentation and interviews revealed ongoing issues with communication and adherence to dietary orders. The facility's policy required that diets be served according to physician orders and that staff check meal trays for compliance with diet cards, but this was not consistently followed. A grievance had previously been filed regarding the resident receiving non-compliant foods, and staff interviews indicated that concerns about the resident's diet and supervision during meals had been raised multiple times without resolution. The administrator confirmed there was no facility policy specifically addressing therapeutic diets, and was unaware that the resident was receiving pleasure trays at every meal.