Failure to Provide Prescribed Ground Meat for Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure that a resident on a mechanically altered diet received food in the prescribed form. During a breakfast meal observation, a resident with severe cognitive impairment was seen sitting up in bed with a meal tray in front of her. The meal ticket indicated she was on a regular diet with ground meat and was to receive scrambled eggs, a ground meat sausage patty with pork gravy, toast, butter, and jelly. Instead, a whole, unground sausage patty without pork gravy was present on the tray. A CNA confirmed that the sausage patty should have been ground and served with pork gravy. Record review showed the resident had diagnoses including dementia, malnutrition, and heart failure. An Annual MDS assessment documented that she was severely cognitively impaired, had complaints of difficulty and pain with swallowing, and was on a mechanically altered diet. The care plan, current through the survey period, identified risk for unintentional weight loss and included an intervention for a regular diet with ground meats and monitoring of food and fluid intake. A current physician’s order also specified a regular diet with ground meats. The Dietary Manager stated that the sausage patty should have been ground before leaving the kitchen. The facility’s Diet Orders policy indicated that the RD or designee would evaluate diet therapy according to each resident’s individual medical condition, needs, desires, and rights.
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