Failure to Provide Prescribed Thickened Liquids for Resident with Dysphagia
Penalty
Summary
The facility failed to provide appropriate care and nutrition services for a resident with dysphagia and a history of cerebral infarction, who was prescribed a ground texture diet with nectar thickened liquids. Despite clear physician orders and a speech language pathology assessment specifying the need for nectar thickened beverages, the resident was observed receiving thin, regular consistency beverages, including cranberry juice and hot tea, during both breakfast and lunch. The unit manager confirmed that the beverages provided were not thickened as ordered, and the speech language pathologist explained that thin liquids posed a risk for the resident, as they could lead to coughing and aspiration due to the resident's swallowing difficulties. The deficiency was identified through observation, interview, and record review, which showed that the facility did not follow the resident's plan of care regarding dietary modifications. The failure to provide thickened liquids as ordered placed the resident at risk for swallowing complications, as noted by both the unit manager and the speech language pathologist. The facility's policy required adherence to therapeutic diet orders, but this was not followed in the resident's case.