Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to ensure that a therapeutic diet was provided to a resident with a nutritional problem, as ordered by the healthcare provider. Specifically, a resident with intact cognition and a diagnosis of dysphagia was observed consuming thin liquids without the required thickener, despite having physician orders for nectar thick liquids. The resident's care plan, initiated due to impaired swallowing, included a diet of pureed food with moderately thick liquids. However, during a dining observation, the resident was provided with juice and a packet of thickener on the tray, but no staff was observed adding the thickener to the juice. Consequently, the resident consumed the juice without thickener and experienced coughing episodes. Interviews with facility staff revealed inconsistencies in the understanding of responsibilities regarding the administration of thickened liquids. The Speech Language Pathologist confirmed the resident's need for nectar thick liquids due to the high risk of aspiration. A CNA stated that nurses were responsible for adding thickener to residents' drinks, while an LPN confirmed this responsibility. However, the Director of Nursing indicated that CNAs were responsible for adding the thickener when serving meal trays. This discrepancy in staff roles and responsibilities contributed to the failure to provide the resident with the appropriate therapeutic diet as ordered.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1 The resident was immediately assessed by the RN supervisor and found to have no ill effects from the lack of thickener. Element #2 The facility purchased pre-thickened fluids to provide to residents that have orders for thickened liquid diet. The Director of Nursing will review all residents with thickened fluids orders to ensure residents are receiving pre-thickened fluids. Element #3 The nursing staff will be educated on the use of thickened fluids. The policy and procedure on thickened fluids will be updated to include the use of pre-thickened fluids and the responsibility of the LPN and CNA to ensure the resident receives thickened fluids. Element #4 An audit tool will be developed by the Director of Nursing to monitor the use of thickened fluids. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of Nursing will present findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5 Director of Nursing 05/01/25