Failure to Review Family-Brought Food for Resident with Dysphagia
Penalty
Summary
The facility failed to implement its policy regarding the review and storage of food brought in by family members for a resident with significant swallowing difficulties. Specifically, a resident with diagnoses including dysphagia, hyperlipidemia, and adult failure to thrive, and who was on a mechanically altered, fortified diet as ordered by the physician, was observed being fed a regular diet of wonton soup and kiwi by a family member. The resident's care plan and physician orders required adherence to a mechanically altered diet due to the risk of choking and aspiration. Despite this, the food brought in by the family was not checked by the Licensed Vocational Nurse (LVN) as required by facility policy. Interviews with the LVN and the Director of Nursing (DON) confirmed that the food was not reviewed for compliance with the resident's prescribed diet, and that the family was not educated on the facility's policy or the resident's dietary needs. The facility's policy required staff to review the diet order with the resident's representative and assist families in understanding safe food handling practices, but this was not followed in this instance.