Failure to Implement Dietary Restrictions for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when staff failed to implement dietary restrictions for a resident with dysphagia and muscle wasting, who was admitted with an order for nectar thickened liquids (NTL) and a specific restriction against the use of straws. Despite the diet order and documentation on the diet ticket indicating no straws, the resident was repeatedly observed with a straw in their water cup on multiple occasions. Staff interviews revealed a lack of awareness or confirmation of the dietary restriction, and the occupational therapist confirmed that the resident should not have a straw due to the risk of coughing and aspiration. The Director of Nursing acknowledged that diet orders are printed and expected to be followed, but the resident continued to have access to a straw. A facility policy regarding special dietary instructions was requested but not provided during the survey. The resident involved had impaired cognition, required staff assistance with mobility and transfers, and was at risk due to the failure to follow prescribed dietary restrictions.