Failure to Provide Ordered Nectar Thick Liquids to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with vascular dementia and dysphagia, who was assessed as moderately cognitively impaired and at high risk for aspiration, was not provided with fluids consistent with the physician's order. The resident's care plan and physician's order specified a mechanical soft diet with nectar thick liquids due to overt signs and symptoms of aspiration. However, during a lunch observation, the resident's meal tray included a cup of thin liquid hot tea instead of the required nectar thick consistency. The nurse aide delivering the tray did not initially notice the inconsistency and only realized the error after reading the meal card, which specified nectar thick hot tea. The resident did not consume the tea, and it was removed from the tray. Interviews with dietary staff and the speech therapist confirmed that the resident's order was for nectar thick liquids and that the thin liquid tea was an oversight by dietary staff. The facility used pre-thickened fluids to avoid such errors, but in this instance, the correct consistency was not provided. The speech therapist had previously evaluated the resident and recommended nectar thick liquids due to a high risk of aspiration. Both the DON and the Administrator acknowledged that the resident should have been served nectar thick liquids as per the physician's order.