Failure to Serve Food According to Physician-Ordered Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for several residents with physician-ordered mechanical soft diets. Multiple observations revealed that staff did not serve food items according to the prescribed menu or diet orders. For example, one resident with an order for a mechanical soft diet was repeatedly served regular texture foods, such as a sausage patty cut into pieces instead of ground sausage with gravy, regular smothered chicken instead of ground chicken, and bacon instead of the prescribed ground sausage. The resident, who wore only top dentures due to ill-fitting bottom dentures, reported difficulty chewing and a preference for soft foods. Additionally, the resident's meal card was outdated and did not reflect the current diet order, leading to further errors in meal preparation and service. Other residents with mechanical soft diet orders were also served inappropriate food items. Two residents were observed receiving cucumber and tomato salad, which was firm and crunchy, instead of the required chopped steamed vegetables. The dietary aide responsible for serving these meals was new and unfamiliar with the specific dietary requirements for each resident, contributing to the errors. Meal tickets for these residents correctly indicated the need for a mechanical soft diet, but the wrong food items were still served. Another resident with a history of esophageal dilation and no teeth, who required a mechanical soft diet with no bread, was served sandwiches on white bread and whole fried chicken breasts, both of which were not suitable for their dietary needs. The resident reported choking on these foods and stated that white bread would get stuck in their throat. Interviews with dietary and nursing staff revealed inconsistencies in the process for updating and using meal tickets, with some staff using outdated cards and others not discarding previous versions. Facility leadership, including the DON, Registered Dietitian, and Administrator, all stated that staff were expected to follow current diet orders and use up-to-date meal cards, but this was not consistently practiced.