A resident with dysphagia and a chopped meat diet order choked after being served a large piece of chicken that was not prepared to the ordered texture. Staff attempted the Heimlich maneuver, back blows, and CPR before EMS removed the chicken from the airway. The resident was hospitalized in critical condition, later required intubation and a G-tube, and speech therapy recommended NPO.
A resident who required a pureed diet was served a lunch entree with visible lumps, and the CNA confirmed the puree was lumpy. The ST stated the resident needed a pureed consistency and that pureed foods should be smooth with no lumps or bumps. The report also identified six additional residents receiving pureed texture who could have been affected.
Incorrect Diet Texture Provided: A resident with cerebrovascular disease, vascular dementia, and severely impaired cognition was ordered a mechanical soft diet with thin liquids and staff feeding assistance. During lunch, the resident was served a biscuit even though the meal ticket indicated soft breads for the mechanical soft diet; the biscuit was later removed after staff questioned the order. An RN confirmed the error, and the ST stated a biscuit is considered a regular diet item, not mechanical soft.
A facility failed to serve altered-texture meals as ordered for residents on mechanical soft and pureed diets. During lunch observation, residents on mechanical soft diets received chicken noodle casserole without gravy and carrot coins instead of chopped carrots, while residents on pureed diets received pureed casserole without gravy. A dietary staff member and the DM verified the meal preparation and service did not match the diet spreadsheet, and the dietician confirmed the ordered textures and gravy were required.
A resident with dementia, severe malnutrition, and dysphagia was ordered a mechanical soft diet with honey-thick liquids, but was observed drinking an unthickened electrolyte drink and later served broccoli that was too hard to cut with a fork. Staff confirmed the liquid had not been thickened before service and that the broccoli did not meet mechanical soft guidelines.
A resident with COPD, schizoaffective disorder, anorexia nervosa, anxiety, and HTN was ordered a regular diet with mechanical soft texture and thin liquids, but was served a whole cube steak instead of the required ground texture. Staff confirmed the resident was on a mechanical soft diet, and the DM verified the meat should have been ground per the ordered diet and the facility's tray identification process.
Meals Not Served in Accordance With Ordered Double Portions: The facility failed to serve meals in a form designed to meet individual needs for two residents. One resident with COPD, bipolar disorder, and alcohol dependence had an order and meal ticket for double portions, but observations and the DON confirmed the lunch tray did not include them. Another resident with bipolar disorder, HTN, and diabetes also had an order for double portions, yet observations, a CNA, and the DON confirmed the resident’s trays did not provide the ordered double portions.
Pureed Foods Not Prepared to Required Consistency: A dietary cook prepared pureed dinner items, but tasting showed the beets had a crunchy texture with liquid separation rather than a smooth puree. The cook stated she had never tasted pureed foods for consistency or taste, and the DM verified the texture was not consistent with the facility’s puree diet standards. The issue had the potential to affect nine residents on a puree diet.
Mechanical soft diet meals were not prepared in the required texture for residents who needed them. Surveyors observed that residents ordered for a mechanical soft diet were served regular texture ham and beans, greens, and cornbread instead of ground or chopped items. The DM confirmed the modified ham and beans were not available, and the dietitian reported minimal kitchen oversight and was unaware of the issue.
The facility failed to prepare and provide food in the correct pureed consistency for several residents with physician-ordered pureed diets. During a lunch meal observation, pureed rice on the steam table was found to be gritty with large clumps instead of smooth, and the Dietary Supervisor confirmed it was not the correct puree texture. Review of the diet list showed multiple residents were ordered pureed diets, and facility policy defined therapeutic diets, including texture-modified diets, as physician- or practitioner-ordered as part of treatment for clinical conditions.
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