Failure to Provide Prescribed Liquid Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to provide liquids consistent with the prescribed needs of two residents who required nectar-thickened liquids due to dysphagia. For one resident with Parkinson's disease and severe cognitive impairment, staff did not ensure that the lunch tray contained nectar-thick liquids as ordered. Instead, the resident was given thin liquids, which he drank. The CNA did not initially notice the inconsistency, assuming the nurse had checked the tray, and only corrected the error after confirming the resident's dietary needs. The nurse responsible for checking trays admitted to misreading the diet card and placing thin liquids on the tray, acknowledging the resident was at risk for aspiration as a result. On a subsequent day, the same resident was found with a bottle of thin liquid water at his bedside, which he had been drinking. Neither the resident nor the staff could identify how the water was provided, and the CNA removed it after being alerted. The nurse assigned to the resident stated she had not seen the water bottle earlier and emphasized that all staff were responsible for ensuring the correct liquid consistency was provided. A second resident, also with severe cognitive impairment and on a nectar-thickened liquid order, was observed with thin liquids in a metal cup at his bedside. The resident reported drinking from the cup with his medications. The CNA, after being questioned, checked the cup and removed the thin liquids, stating she had not previously checked the contents. The speech therapist confirmed both residents were on nectar-thick liquids, and the DON and Administrator stated that staff were expected to follow prescribed diets and ensure correct liquid consistency, as outlined in facility policy.