Failure to Provide Prescribed Nectar Thick Liquids to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with dementia and dysphagia, who was ordered to receive nectar thick liquids, was provided with a cup of tea of thin liquid consistency during a lunch meal service. The resident's care plan and diet card both indicated the need for nectar thick liquids, but the meal tray included thin tea. A nurse aide recognized the inconsistency and removed the tea from the resident's hand but did not remove it from the tray or out of the resident's reach. The resident subsequently picked up the cup and took a sip, resulting in a cough. The Business Office Manager, unaware of the resident's dietary restrictions, provided a straw for the tea, further enabling access to the thin liquid. Interviews revealed that the nurse aide relied on the diet card to verify the meal but did not anticipate the resident would reach for the tea. The Business Office Manager was not aware of the resident's thickened liquid order and assumed the tea was appropriate since it was on the tray. The Speech Therapist confirmed that the resident's diet order for nectar thick liquids was in place to prevent aspiration and that thin liquids should not have been served with meals. The administrator acknowledged that the resident was not provided with fluids of the prescribed consistency as ordered by the physician.