F0692

D

Failure to Control Off‑Diet Peanut Butter and Jelly for Resident on Pureed, Nectar‑Thick, CCHO Diet

Jackson, California Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that food available to a resident was consistent with the physician‑ordered pureed diet with mildly thick (nectar‑thick) liquids and a consistent carbohydrate (CCHO) plan. The resident had multiple diagnoses, including diabetes mellitus, anemia, atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease, and was on aspiration precautions with safe swallowing instructions posted at the bedside. Despite these orders and precautions, surveyors observed a jar of Smucker’s Goober Strawberry Peanut Butter & Jelly Stripes on the resident’s bedside table within reach. The resident reported that he did not like the pureed food served by the facility, acknowledged having difficulty swallowing, and stated that he had been eating peanut butter and jelly directly from the jar since the previous year without being told it could be unsafe.

Nursing and CNA staff were aware that the resident was sometimes non‑compliant with the prescribed diet and had seen him eating peanut butter and jelly, but they did not recognize or act on the potential conflict with his ordered pureed/nectar‑thick, CCHO diet. The LN confirmed the resident’s diet order and aspiration precautions, acknowledged seeing him eat peanut butter and jelly, and admitted uncertainty about whether it was safe. The CNA stated that the resident did not like the pureed food, had observed him eating peanut butter and jelly as a snack, and knew he was sometimes non‑compliant with his diet, but was not aware of his swallowing precautions and did not know that peanut butter and jelly could be unsafe for him. Neither staff member reported the issue through the facility’s processes or sought further assessment of the resident’s swallowing in relation to this food.

The dietary and therapy departments were also not informed of the resident’s ongoing consumption of peanut butter and jelly. The Certified Dietary Manager, upon review of the electronic health record, confirmed the resident’s CCHO diabetic dysphagia diet with pureed texture and nectar‑thick liquids and stated that peanut butter and jelly did not meet the physician‑ordered diet due to both texture and sugar content. The Speech Therapist reported that she had not evaluated the resident for some time, was unaware that he was eating peanut butter and jelly directly from the jar, and had never assessed his ability to safely swallow that food. The resident’s significant other stated that she had been bringing peanut butter and jelly for about three months, that staff had told her she could bring any food she wanted, and that she continued to bring it because the resident would not eat otherwise, despite being aware there could be safety concerns. The facility’s policy on resident food preferences required the dietitian and nursing staff, with physician involvement, to address conflicts between resident preferences and prescribed diets, but this process was not implemented in relation to the resident’s peanut butter and jelly consumption.

Overall, the facility did not ensure that the resident’s available food was consistent with the ordered pureed, nectar‑thick, CCHO diet, did not communicate or coordinate among nursing, dietary, and therapy staff regarding the resident’s off‑diet food brought by family, and did not follow its own policy for managing resident food preferences that conflict with prescribed diets. This resulted in the resident having independent access to and consuming peanut butter and jelly that did not conform to his physician‑ordered diet and swallowing precautions.