Failure to Implement Physician Order for Thickened Liquids
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when the facility failed to implement a physician's order for mildly thickened liquids for a resident with dysphagia. The resident, who was cognitively impaired and required mildly thickened liquids per hospital discharge orders, did not have this requirement reflected in the nutrition care plan. Multiple observations showed the resident had access to thin liquids at the bedside, and several CNAs confirmed they were unaware of the thickened liquid order. The RN Case Manager acknowledged that the care plan did not include the physician's order, which led to staff providing thin liquids instead of the prescribed consistency.