Failure to Provide Prescribed Liquid Consistency for Resident with Dysphagia
Penalty
Summary
A resident with a physician's order for nectar-thick liquid consistency due to dysphagia was served regular thin liquid coffee during lunch. The Certified Nursing Assistant (CNA) assisting the resident did not check the consistency of the coffee before serving it and acknowledged that the resident should not have received a thin liquid. The resident's medical record indicated a diagnosis of dysphagia, a history of swallowing problems, and dietary orders specifying puree texture and nectar-thick liquids. The Registered Dietician (RD) confirmed that both dietary and nursing staff are required to follow dietary orders and that serving a thin liquid instead of nectar-thickened liquid could lead to choking or aspiration. The facility's diet manual also outlined the required consistencies for liquids and pureed foods, emphasizing the need for proper preparation to meet individual needs. The failure to provide the prescribed liquid consistency was directly observed and confirmed through staff interviews and record review.