Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
A registered nurse administered thin liquids to a resident who had a physician's order for pudding-thick liquids. During a random observation, the nurse gave the resident a soufflé cup of crushed medications mixed with pudding, followed by two separate servings of approximately 60 ml of cold water, which the resident drank and swallowed. The resident did not respond verbally or physically to the nurse's questions about wanting a drink. The nurse then escorted the resident to the dining room for lunch. The resident's medical record indicated diagnoses including paraplegia, dysphagia, diabetes, cerebral infarction, bladder dysfunction, and chronic kidney disease. The most recent assessment documented severe cognitive impairment, a mechanically altered diet, and total dependence on staff for all activities of daily living, including eating. The facility's current policy required pudding-thick liquids for this resident, and the nurse later acknowledged she should not have given unthickened water, stating she did not know why she had done so.