Failure to Provide Physician-Ordered Food and Liquid Consistencies
Penalty
Summary
Two residents with dysphagia did not receive food and liquids prepared in the appropriate consistency as ordered by their physicians and recommended by speech-language pathologists. One resident, with a history of dysphagia and moderate cognitive impairment, was on a pureed diet with honey-thickened liquids and aspiration precautions. During a meal observation, the resident was found drinking unthickened hot water and milk, resulting in coughing episodes, while the thickener packet remained unopened. The LPN present was an agency nurse unfamiliar with the residents and did not ensure the liquids were thickened as required. Another resident, also with dysphagia and moderate cognitive impairment, was ordered a dysphagia Level Two (ground solids) diet with thin liquids and aspiration precautions. The resident's meal ticket specified pureed braised cabbage, but the lunch tray contained shredded cabbage that was not pureed. Staff initially misidentified the food consistency, and the speech-language pathologist later confirmed it was not pureed as required. Facility policies specified the need to adhere to prescribed food and liquid consistencies, but these were not followed for the two residents.