Failure to Provide Prescribed Thickened Liquids to Resident with Swallowing Difficulties
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of senile degeneration of the brain and a history of difficulty swallowing was not consistently provided with food and liquids in the prescribed form. The resident's care plan and physician orders required nectar thickened liquids, but observations on two separate days revealed that regular water was present at the bedside. A family member admitted to giving the resident regular water, believing it was acceptable since it was available in the room, but acknowledged the resident had difficulty swallowing and agreed to stop after being informed. Staff interviews revealed a lack of clear identification or visual cues for residents requiring thickened liquids. The hospitality aide responsible for passing water was unaware of the importance of providing only thickened liquids to certain residents and believed, based on unclear communication, that both regular and thickened water could be given. The DON confirmed that staff were expected to know which residents required thickened liquids based on reports, but no visual system was in place to assist with this. Facility policy required an identification system to ensure residents received the ordered diet, but this was not implemented, resulting in the resident being served inappropriate liquids.