Failure to Provide Prescribed Diet for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with oropharyngeal phase dysphagia, who had a physician's order for a regular diet with heavily iced liquids, was not provided with the prescribed diet. Observations during meal service revealed that the resident was repeatedly offered a yellow liquid without ice by a certified nursing assistant. After consuming the non-iced liquid, the resident was observed to clear her throat and cough. The speech therapist, present during one of the observations, confirmed that the liquid did not meet the prescribed requirement for heavily iced liquids. Interviews with facility staff, including the speech therapist, LPN, registered dietician, and director of nursing, all confirmed that the resident should have received heavily iced liquids as per the physician's order. The failure to provide the correct diet was contrary to the facility's policies on therapeutic diets and assistance with meals, which require adherence to physician orders and individualized resident needs.