Neglect Resulting in Harm Due to Improper Fluid Consistency Provided by Volunteer
Penalty
Summary
The facility failed to protect a resident from neglect when a volunteer provided a drink of thin liquid to a resident with physician orders for nectar thickened fluids. The resident, who had diagnoses including dysphagia, dementia, and muscle weakness, was in the activity room when the volunteer, without consulting nursing staff, gave the resident a thin liquid beverage. Facility policy and volunteer guidelines specifically instructed that volunteers should not provide food or drink to residents without first asking the resident's nurse, and that pre-thickened liquids should be provided per physician orders. As a result of receiving the incorrect liquid consistency, the resident began coughing and subsequently developed bilateral lobe pneumonia with a small left-sided effusion, as confirmed by a chest X-ray. The incident was documented in the clinical record and facility investigation, with staff interviews confirming that the volunteer did not follow established protocols regarding dietary restrictions and fluid consistencies for residents with swallowing difficulties.