Failure to Follow Ordered Mechanical Soft Therapeutic Diet
Penalty
Summary
The facility failed to provide an ordered therapeutic diet to a resident who had a physician order dated 2/1/26 for a regular diet with mechanical soft texture and thin consistency, and speech therapy documentation for mechanical soft/chopped textures with dysphagia precautions. On the morning of 2/19/26, signage above the resident’s bed indicated a mechanical soft diet with chopped meats and thin liquids. At lunchtime the same day, the resident was observed feeding himself without staff present, and his meal tray contained approximately seven potato chips and two saltine crackers. The meal ticket on the tray read “Regular-DYS ADV,” indicating a regular diet avoiding hard, sticky, or crunchy foods, with foods to be bite-sized. During subsequent interviews, a CNA, the Unit Manager, the Speech Pathologist, and the Certified Dietary Manager each stated that chips and crackers are not appropriate for a mechanical soft texture diet and should not have been on the tray. The Certified Dietary Manager stated that dietary staff are expected to read each meal ticket and place food on the tray according to the therapeutic diet, and acknowledged that the chips and crackers should not have been included. The Regional Nurse Consultant, acting as DON, and the Administrator both stated their expectations that staff follow therapeutic diets according to meal tickets and physician orders, confirming that the observed tray contents did not align with the ordered mechanical soft diet and dysphagia-related precautions documented for the resident.
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