Failure to Provide Physician-Ordered Liquid Consistency
Penalty
Summary
A deficiency occurred when the facility failed to provide a physician-ordered liquid consistency for a resident who had been downgraded to nectar thick liquids. The resident, initially admitted on a regular diet with thin liquids, was observed coughing while drinking thin liquids, prompting a downgrade to nectar thick liquids as ordered by the physician. Despite this order, the resident continued to be served thin liquids on multiple occasions. Staff members, including a CNA and two COTAs, provided the resident with thin juice, either due to confusion over the menu ticket or lack of awareness of the updated dietary order. The CNA served thin juice because the menu ticket listed both thin and nectar options, and she did not notice the nectar order. Both COTAs were unaware of the change to nectar thick liquids and provided regular juice to the resident during their interactions. The facility's policy required that all diet and texture modifications be physician-ordered and that nursing and dietary staff ensure correct diet trays are served. However, the failure to communicate the updated dietary order and ensure staff adherence resulted in the resident receiving the incorrect liquid consistency. The observations and staff interviews confirmed that the resident was repeatedly given thin liquids after the downgrade order, contrary to the physician's instructions and facility policy.