Failure to Provide Physician-Ordered Thickened Liquids
Penalty
Summary
The facility failed to provide liquids at the physician-ordered consistency for a resident with a history of Parkinson's disease and dementia, who was prescribed a mechanically soft diet with nectar-thickened liquids. During meal observation, the resident was found with a cup of juice containing ice cubes, which altered the consistency of the nectar-thickened liquid, and was also observed coughing frequently while being assisted with eating. Staff present could not account for how the juice with ice was provided, and the dietician confirmed that ice should not have been present in thickened liquids. Additionally, during a medication pass, a nurse provided the resident with regular water from a medication cart instead of the required thickened liquid, resulting in the resident coughing upon swallowing. The nurse did not respond when questioned about reading the medication administration record (MAR) or using the thickened liquid available in the resident's room. The assistant director of nursing confirmed that thickened liquids should be available on every medication cart and that the MAR should indicate the resident's dietary needs, but the required thickened liquid was not present on the cart used.