Failure to Provide Prescribed Thickened Liquids
Penalty
Summary
A deficiency occurred when the facility failed to provide drinks in a form that met the individual needs of a resident. The facility's policy required that all physician or provider orders, including those related to diet and nutritional supplements, be transcribed and reviewed by the charge nurse. The resident in question had diagnoses of high blood pressure, diabetes, and dementia, and was assessed as requiring a mechanically altered diet with thickened liquids at honey consistency, as documented in both the Minimum Data Set and the care plan. Physician orders specifically indicated the need for thickened liquids. During an observation, the resident was found in bed with a cup of clear thin liquid within reach, rather than the prescribed thickened liquid. An LPN confirmed that while thickener appeared to have been added, staff failed to mix it properly and ensure it reached the correct consistency. The DON also confirmed that the facility did not provide the drink in the required form for this resident.