Failure to Provide Prescribed Altered Diet Textures and Thickened Liquids
Penalty
Summary
The facility failed to provide food and liquids in the prescribed texture and consistency for three residents who required altered diets for chewing or swallowing needs. One resident with diabetes, hypertension, and COPD had a physician’s order and dietitian assessment specifying a mechanical soft diet with chopped meats. Despite a diet card indicating chopped meat, this resident was served a regular consistency Salisbury baked steak that had not been chopped, and she began eating the meat in its regular form. The DON confirmed the meat should have been chopped, and later explained this was necessary because the resident refused to wear her dentures. Another resident with Kufor-Rakeb Syndrome and dysphagia had a hospital discharge summary and physician’s order requiring honey-thick liquids based on a prior modified barium swallow. This resident, who had moderately impaired cognition, was observed receiving unthickened water and Kool-Aid. An RN initially believed the thickened liquid order had been discontinued but, upon checking the physician’s orders, confirmed that honey-thick liquids were still required and then thickened the drinks. A third resident with dementia, dysphagia, and no lower teeth had a physician’s order for a mechanical soft diet with ground meats and a care plan noting swallowing risk and partial denture use. This resident was observed receiving a regular consistency Salisbury baked steak instead of ground meat. The DON confirmed the meat was not ground as ordered. The dietary manager described facility procedures for chopped and ground meats, and the written procedure stated that diets are to be modified in texture and individualized based on chewing and swallowing ability.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.