Failure to Provide Thickened Liquids as Ordered for Residents with Dysphagia
Penalty
Summary
The facility failed to follow physician-ordered diet instructions regarding fluid consistency for two residents with dysphagia. One resident, with a history of acute respiratory failure with hypoxia and gastro-esophageal reflux, was observed drinking regular water despite an order for nectar-thick liquids. The resident's meal ticket also indicated the need for thickened liquids, and this was confirmed by the Activity Director, who acknowledged that the water should have been thickened as per the order. Another resident, also diagnosed with acute respiratory failure with hypoxia and pneumonia, was observed coughing after drinking hot chocolate that was not thickened, despite an order for nectar-thick liquids. The Director of Nursing confirmed that the drink should have been thickened according to the resident's meal ticket and physician's order. The facility's policy on nutritional management of thickened liquids emphasizes the importance of following thickened liquid orders to prevent aspiration in residents with dysphagia.
Plan Of Correction
Drinks Available to Meet Needs/Preferences/Hydration How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #49 and Resident #79 were provided with thickened beverages according to their diet orders on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct beverages according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025