Failure to Follow Ordered Diet Texture and Dessert for Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided met professional standards of quality by not following the comprehensive care plan and diet orders for one resident. The resident was an older man with dementia with psychotic disturbance, dysphagia, and unspecified protein-calorie malnutrition, and required dentures. His care plan identified a potential nutritional problem and a swallow problem related to dysphagia, with instructions for staff to monitor for swallowing difficulties and to ensure the prescribed diet was followed, with goals of no choking episodes and no signs of aspiration. Record review showed an active physician order for a renal diet with regular texture and regular consistency, and a discontinued order for a renal diet with mechanical soft texture. However, during meal tray preparation, the resident’s meal ticket listed a renal diet with mechanical soft texture and specified a dessert of 1/2 cup crushed pineapple. Instead of the ordered crushed pineapple, the tray was assembled with a cup of Nilla Wafer cookies as dessert and passed from dietary to an RN and then to the activities director for delivery. When observed, the resident, who did not have teeth, stated he could eat the cookies only if he drank enough water and indicated he preferred the crushed pineapple listed on his meal ticket. Interviews revealed inconsistent understanding and communication of diet orders among staff. The Dietary Manager stated that Nilla Wafers were considered safe for mechanical soft diets when served with pudding and that dietary staff relied on written communication forms from nursing or speech therapy for diet changes; he reported having no such form for this resident. The Director of Rehabilitation stated the resident had been evaluated by speech therapy and was on a regular diet with thin liquids, and that speech therapy did not communicate diet orders directly to the kitchen, expecting nursing to complete and deliver diet order forms. RN A reported relying on dietary staff’s statement that Nilla Wafers were mechanical soft, was unaware of the regular diet order in the chart, and described a process in which nursing created and sent diet sheets to dietary. RN B stated the resident could eat a regular diet but was supposed to be on mechanical soft due to not using dentures, and did not recall completing a communication form for a regular diet order. The Regional Nurse described expectations that dietary staff and nurses check meal tickets and meals before delivery and that speech-initiated diet changes be entered into the chart and confirmed by nursing before being sent to dietary, underscoring that this process was not effectively followed for this resident’s dessert.
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