Noncompliance with Puree Diet Order for Resident with Dysphagia
Penalty
Summary
A resident with a diagnosis of dysphagia and a physician-ordered fortified puree diet with nectar/mildly thick liquids was given cotton candy by the Business Office Manager. The resident's care plan and dietary profile both specified the need for a puree texture diet due to swallowing difficulties, and the goal was to ensure safe consumption of food without signs of aspiration. Despite these orders, the Business Office Manager provided the resident with cotton candy after previously asking the former DON if it was permissible. The Registered Dietitian confirmed that the resident should not have been given cotton candy, and the Assistant Director of Nursing stated that staff should communicate with nursing before providing any treats or snacks to residents on special diets. The incident was observed by an LVN, who noted the resident consuming cotton candy and confirmed the resident was at high risk for aspiration. The facility's policy on therapeutic diets required that snacks be compatible with the prescribed diet. The failure to adhere to the prescribed puree diet and provide food in the appropriate form as ordered by the physician resulted in a deficiency, as it placed the resident at risk for choking or aspiration.