Failure to Follow Physician-Ordered Diet Restrictions for Swallowing-Impaired Resident
Penalty
Summary
The facility failed to follow a physician's order regarding dietary restrictions for a resident with a swallowing impairment. The resident had a documented history of laryngeal/pharyngeal impairment and penetration of liquids when using a straw, leading to a specific physician order prohibiting the use of straws. Despite this, observations on two occasions revealed a cup with a straw filled with fresh ice water in the resident's room. A sign above the resident's bed clearly stated that no straws were to be used. Interviews confirmed that staff were aware of the no-straw restriction, and the family provided appropriate drinking cups for the resident. However, the Business Office Manager, who was assisting with distributing morning ice and water, was unaware of the restriction and placed the lidded cup with a straw in the resident's room. This oversight resulted in the resident not receiving care in accordance with the physician's order and established dietary restrictions.