Mechanically Altered Diet Order Not Followed for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that food was prepared and served in a form designed to meet an individual resident’s ordered mechanically altered diet. One resident with an admission date of 05/17/22 had diagnoses including vascular dementia (moderate) with behavioral disturbance, COPD, essential hypertension, and adult failure to thrive. A physician’s order dated 01/13/25 directed that this resident receive a regular diet with mechanical soft texture and regular consistency, with regular texture food/snacks as desired and with supervision. The care plan dated 06/09/25 identified the resident as being at risk for malnutrition/alteration in nutritional status related to dementia with behaviors, history of failure to thrive, depression/anxiety, diabetes, COPD, and cerebrovascular accident, and documented that the resident was to receive a mechanically altered diet and snacks with supervision. An Annual MDS dated 12/04/25 showed the resident had severe cognitive impairment. During a meal service observation on 01/06/26 at 12:24 P.M., the resident was served mechanically altered meatballs, unaltered green beans, and whole grapes. The resident was observed eating the grapes whole while alone in the room, without staff present to provide supervision. At 12:25 P.M., an LPN confirmed the resident was ordered to receive a mechanically altered meal and verified that whole grapes are not considered mechanically altered. At 12:40 P.M., another staff member confirmed the resident’s mechanically altered diet order and stated that whole grapes should not have been served to any resident on a mechanically altered diet due to whole grapes being a choke risk. Review of the facility’s 2021 “Texture and Consistency-Modified Diets” policy indicated that a physician order is required for a modified diet and that the food and nutrition services department is responsible for preparing and serving the correct food consistency as ordered.
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