Failure to Honor Cognitively Intact Resident’s Refusal of Therapeutic Diet Consistency
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident could exercise the right to refuse a physician‑ordered therapeutic diet and meal consistency. The resident had an order for a NAS pureed diet with nectar/mildly thick liquids and no straws, based on a video swallow evaluation that recommended minced & moist food texture and thin liquids by cup in a chin‑tuck position or nectar‑thick liquids. The resident’s care plan for non‑compliance with diet and fluid recommendations included interventions to educate on risks and benefits, observe for signs and symptoms of aspiration, and respect the resident’s right to refuse recommendations. The MDS showed a BIMS score of 15, indicating the resident was cognitively intact. IDT notes documented that the NP discussed the risks of non‑compliance with the ordered pureed diet and thickened liquids, including that the resident’s pneumonia was likely caused by aspiration and that continued non‑compliance made aspiration very probable. The NP documented that the resident stated, “I don’t care if this is what kills me.” Despite this, the facility continued to enforce the ordered pureed/nectar‑thick diet without honoring the resident’s expressed refusal of the prescribed meal consistency. Nursing notes described that when the resident wanted to participate in a Christmas hot chocolate bar and treats, the DON confirmed with the provider that participation was allowed only if items met the ordered texture requirements; when this was explained, the resident declined and returned to her room. Observation showed an untouched lunch tray with multiple pureed items at the bedside, and the resident reported she did not eat the pureed foods, only desserts, and that she had told the NP she frequently had pneumonia but the diet was not changed. She stated she wanted food “the way I want it,” acknowledged she was “stubborn,” and said the facility must bring the food but knew she would not eat it. The DON stated the facility did not have waivers for residents who refuse therapeutic diets and did not offer a minced & moist texture, despite the VSE recommendation. The facility’s own Patient Rights and Responsibilities policy stated that patients have the right to make decisions regarding medical care, receive information needed to give informed consent or refuse treatment, and are responsible for their actions if they refuse treatment or do not follow physician instructions.
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