Failure to Follow NPO Orders and Ensure Nutritional Safety
Penalty
Summary
The facility failed to provide appropriate nutritional treatment and services for a resident with dietary orders for nothing by mouth (NPO). Upon admission, the resident had a history of pneumonia, dysphagia, respiratory failure, and required a gastrostomy tube (G-tube) for nutrition. Despite clear orders and documentation indicating the resident was NPO and at high risk for aspiration, staff did not properly assess or clarify dietary needs at admission. On the day of admission, an LPN provided the resident with two ham and cheese sandwiches and ice water, without confirming the hospital discharge orders or recognizing the presence of a G-tube. This resulted in the resident aspirating and subsequently being hospitalized for aspiration pneumonia. The deficiency was further compounded when, after the resident's return to the facility, a food tray was again provided to the resident despite ongoing NPO orders and clear recommendations from speech therapy. The meal ticket system failed to reflect the correct NPO status, and a CNA unfamiliar with the resident gave the food tray, which led to the resident having food in his mouth. The error was identified and corrected by a supervisor, but not before the resident was exposed to further risk. Interviews with staff confirmed that communication breakdowns occurred between nursing, dietary, and therapy departments, and that the meal ticket system did not always accurately display specialized diets. Throughout the resident's stay, there were multiple documented instances of aspiration, pneumonia, and hospitalizations directly related to the failure to follow NPO orders. Staff interviews revealed that the admitting nurse did not verify discharge orders upon admission, and that subsequent communication lapses and system errors led to repeated provision of food to the resident. The facility's own policies required timely review and clarification of dietary orders, but these were not consistently followed, resulting in the resident not receiving the necessary care and services to meet nutritional needs.