Failure to Provide Physician-Ordered Minced and Moist Diet
Penalty
Summary
A resident with a history of dysphagia and recent emergency room visits for increased cough, congestion, and concerns for aspiration pneumonia was placed on a physician-ordered minced and moist diet with thin liquids. The order, based on the IDDSI Level 5 guidelines, specifically excluded regular, dry bread, sandwiches, or toast. Despite this, the resident was provided a roll for lunch while on the modified diet. Following the consumption attempt, the resident was unable to swallow secretions and vomited upon swallowing food or drink, which led to another emergency department visit. Interviews with facility staff, including the Rehab Director and Director of Nursing, confirmed that the dietary order was not followed and that bread is not permitted on the minced and moist diet per IDDSI standards.