Failure to Provide Physician-Ordered Pureed Diet
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dysphagia, vascular dementia, and decreased appetite, who was severely cognitively impaired and required a pureed diet with thick liquids, was served a breakfast meal that did not meet the prescribed pureed consistency. The resident's care plan and physician's order specified a pureed texture and thick liquids, and the meal ticket reflected these requirements. However, during observation, the resident was served eggs with a baked cheese topping and regular consistency oatmeal with visible oats, neither of which met the pureed standard as defined by facility recipes and staff descriptions. Interviews with nursing and dietary staff revealed inconsistencies in understanding and preparing pureed diets. The nurse assisting the resident believed the meal was appropriate, despite the eggs and oatmeal not being pureed. Dietary staff admitted to not pureeing the eggs due to concerns about texture and stated that oatmeal was never pureed, contrary to recipe instructions. The dietary manager confirmed that the recipe for pureed eggs and oatmeal was not followed and that the resident should have received a pureed meal as ordered. Further, the DON verified that the eggs were not of pureed consistency and stated that discrepancies in meal preparation should be reported, but she was not notified of the issue. The administrator acknowledged that residents must receive the physician-prescribed diet and consistency. The failure to provide the correct food texture was confirmed through direct observation, staff interviews, and review of dietary procedures and documentation.