Failure to Implement Care-Planned Puree Diet and Weekly Weights
Penalty
Summary
Facility staff failed to consistently implement a person-centered comprehensive care plan for one resident with dysphagia, vascular dementia, stridor, and cerebral infarction. The resident’s admission MDS showed a BIMS score of 2/15, indicating severely impaired cognitive skills for daily decision making, and Section K documented a mechanically altered diet. The resident’s care plan identified risk for weight loss or malnutrition related to chronic disease, cognitive impairment, need for assistance with eating, and dysphagia requiring a puree diet, with an intervention for weekly weights initiated on 12/22/25. However, clinical record review revealed only two documented weights over approximately a one-month period, despite the weekly weight intervention, with weights recorded on 12/31/25 and 01/30/26. The facility also failed to consistently provide the correct diet texture as ordered and care planned. A provider order dated 12/19/25 specified a regular diet with dysphagia advanced texture and thin liquids, which was changed on 12/22/25 to a puree diet per hospital recommendations. On observation during a lunch meal, a CNA questioned the consistency of the resident’s chicken; the dietician stated the chicken needed more liquid, and the SLP determined the chicken was a mixture of mechanically altered and pureed and stated it would not be safe for this resident to eat. In a family interview, a family member reported concerns that the resident had not been receiving the correct diet, including being given a milkshake containing Oreo cookies and Reese’s Pieces on Super Bowl Sunday and receiving the wrong meal trays on three occasions. Facility administrative staff later terminated a CNA for providing the wrong texture milkshake. These findings demonstrated that the resident’s care-planned puree diet and weekly weights were not consistently implemented.
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