F0805

D

Failure to Provide Ordered Mechanical Soft Diet Consistency

Kankakee, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in which a resident did not receive a mechanically soft diet as ordered by the physician. During a lunch observation, the resident was seen being fed a meal that included sautéed broccoli, mandarin oranges, a chicken salad sandwich, potato chips, and nectar-thick root beer. The resident’s POS documented an order for a regular diet with mechanical soft texture and nectar/mildly thick liquid consistency. The resident’s care plan, developed due to risk for altered nutrition/hydration status related to frequent propelling, coughing/choking episodes, increased lethargy, and need for feeding assistance, included an intervention to provide and serve the diet as ordered, specifying mechanical soft foods and nectar-thick liquids.

The facility’s dietician stated that potato chips are not appropriate for a mechanical soft diet because of their crunchy texture and the associated risk of difficulty chewing and choking, and confirmed that the resident should not have received potato chips. The dining room supervisor reported that the resident’s daughter completed the menus and that she transcribed the request for chips without realizing it conflicted with the mechanical soft diet order. The dining room service director, who serves as a second check in the kitchen to ensure meals match prescribed diets, acknowledged that she missed the incorrect plating of the resident’s tray. Both dietary staff members agreed that potato chips should not have been served to a resident on a mechanical soft diet. The facility’s policy on oral nutrition and feeding assistance requires that residents receive nutrition and hydration in accordance with the care plan, diet order, swallowing precautions, and interdisciplinary guidance.