Failure to Provide Prescribed Fluid Consistencies Results in Resident Harm
Penalty
Summary
The facility failed to ensure that residents with physician-ordered thickened liquids received drinks in the appropriate consistency, resulting in actual harm to one resident. One resident with diagnoses including dysphagia, dementia, and muscle weakness had a physician order for nectar thickened fluids. Despite this, the resident was given a thin liquid drink by a volunteer during an activity, which led to the resident coughing immediately after ingestion. The incident was documented in the clinical record and confirmed by the volunteer, who admitted to providing the thin liquid without thickening it first. A subsequent chest x-ray revealed the resident developed bilateral lobe pneumonia with a small left-sided effusion, and the resident required antibiotic treatment. Another resident, also diagnosed with dysphagia, dementia, and muscle weakness, had a physician order for nectar thickened liquids and no straws. However, observation revealed a Styrofoam cup with a straw containing thin liquid water at the resident's bedside. The nurse aide responsible for passing the water was unaware of the thickened liquid order and confirmed that the resident was dependent on staff for drinking. The speech language pathologist also confirmed that the resident should be receiving nectar thickened liquids per the current order. Facility policy required that pre-thickened liquids be provided per physician orders and that volunteers not provide food or drink to residents without consulting nursing staff. Despite these policies, both a volunteer and a nurse aide failed to follow the prescribed fluid consistencies for residents with dysphagia, resulting in one resident suffering actual harm and another being placed at risk.