Resident Given Incorrect Liquid Consistency Due to Failure to Verify Diet Order
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, recent TIA, and prior NPO status with PEG tube was given regular thin liquids by a physical therapist during a hallway therapy session. The resident had a current physician order for a mechanical soft diet with nectar thickened fluids, as confirmed by recent swallow studies and speech therapy notes. Despite this, the physical therapist provided the resident with a cup of water, believing the resident had been upgraded to thin liquids based on a misunderstanding from a previous staff meeting. The therapist did not verify the resident's current diet order in the electronic medical record before providing the water. A licensed practical nurse observed the therapist giving the resident water and questioned whether the resident was supposed to receive thin liquids, as she believed the resident was still on a thickened liquid diet. The therapist insisted the resident was doing well and had been upgraded, but the nurse checked the electronic record and confirmed the resident was still on nectar thickened liquids. Before the cup could be removed, the resident drank a large amount of water and subsequently coughed. The incident was witnessed by staff, and the water was removed from the resident. Interviews with the speech therapist, director of nursing, registered dietician, and director of rehabilitation confirmed that the resident was not to receive thin liquids except under the supervision of speech therapy. All staff interviewed stated that the standard protocol is to verify diet orders in the electronic medical record before providing food or fluids, and that non-nursing staff should consult nursing staff before giving anything to eat or drink. The physical therapist admitted to not checking the current order and relying on memory, which led to the resident being given the wrong liquid consistency.