Failure to Enforce NPO Orders for Resident with Dysphagia
Penalty
Summary
The facility failed to adhere to physician orders and its own policy regarding the provision of food in a form appropriate to individual resident needs. Specifically, a resident with diagnoses including high blood pressure, dysphagia, and cancer was admitted with an order for an NPO (nothing by mouth) diet and was receiving nutrition via a feeding tube. Despite this, the resident was observed with a large Styrofoam cup of ice chips and a spoon at her bedside, which was confirmed by a registered nurse to be inconsistent with the NPO order. Further review revealed that the resident's clinical record included an order for a 'holiday free diet,' which conflicted with the NPO status. The Director of Nursing confirmed that the resident should not have had an order for a holiday free diet while under NPO restrictions. The facility's policy clearly states that no food, liquid, or medication should be administered by mouth to residents with an active NPO order unless specifically directed by a physician or speech-language pathologist, and all staff are required to strictly adhere to these orders. The failure to follow these protocols resulted in the deficiency.