Failure to Provide Prescribed Adaptive Dining Equipment for Resident with Dysphagia
Penalty
Summary
A resident with multiple sclerosis and dysphagia was admitted to the facility and had a care plan that included aspiration precautions. Following a documented choking episode, the care plan was revised to require staff-assisted feeding using a small maroon dysphagia spoon at all meals, as recommended by the speech-language pathologist. A physician's order also specified that the resident was to receive meals with the maroon spoon due to dysphagia and aspiration risk, along with a prescribed puree diet and honey-thick liquids. During a breakfast observation, the resident was served and fed with a standard silver teaspoon instead of the prescribed maroon spoon. The nurse aide feeding the resident confirmed that the maroon spoon was not present or used. The Nursing Home Administrator acknowledged that the facility failed to provide and use the prescribed adaptive equipment in accordance with the physician's orders.