Failure to Provide Ordered Thickened Liquids for Resident with Dysphagia
Penalty
Summary
A resident with a history of dysphagia, recent pneumonia, and COVID-19 was ordered to receive a pureed diet with nectar thickened liquids following recommendations from a speech language pathologist and physician orders. The resident's care plan and tray card specified the need for nectar consistency liquids due to aspiration precautions. Despite these orders, during a noon meal observation, the resident was served regular consistency milk and coffee by facility staff. The resident consumed the thin liquids and subsequently experienced coughing after drinking the milk. The surveyor reviewed the resident's tray card and confirmed that the liquids provided did not match the ordered nectar consistency. The interim DON was asked to verify the consistency and confirmed that the liquids were not thickened as required. This incident was identified during a random observation and was determined by the State Agency to have placed the resident at immediate risk for serious harm or death due to the failure to provide liquids in the prescribed consistency. The deficiency was based on direct observation, record review, and staff interview, confirming that the facility did not ensure the resident received liquids consistent with their individualized needs and physician orders.