Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
Staff failed to provide food and liquids in the prescribed form for a resident with a physician order for a pureed diet and nectar thick liquids. The resident, who had moderate cognitive impairment, swallowing difficulties, and a diagnosis of gastro-esophageal reflux disease, was observed receiving unthickened chocolate milk and water on multiple occasions. The resident's care plan and physician orders clearly indicated the need for thickened liquids, but these were not consistently provided. Multiple staff members, including CNAs, a CMT, and LPNs, were unaware of the resident's thickened liquid requirement or did not check the diet card or physician orders before serving drinks. Staff interviews revealed a lack of awareness and communication regarding the resident's dietary needs, with several staff stating they did not know the resident was on thickened liquids or that they relied on nurses or diet cards for updates. Observations confirmed that the resident was given regular liquids, including chocolate milk and ice water, which were not thickened as ordered. The dietary manager confirmed that while the kitchen provides thickened liquids per orders, nursing staff are responsible for preparing thickened chocolate milk and water throughout the day. Despite clear orders and documentation, the resident continued to receive unthickened liquids, and staff interviews indicated ongoing confusion about the resident's dietary requirements. Facility leadership, including the DON and administrator, acknowledged that staff should follow physician orders for thickened liquids but were not aware that the orders were not being followed.