Failure to Provide Diet Texture Consistent With Dysphagia Order
Penalty
Summary
The deficiency involves the facility’s failure to provide food in a form consistent with a physician-ordered modified diet for a resident with dysphagia and severe cognitive impairment. The resident had diagnoses including dementia, oropharyngeal phase dysphagia, and protein-calorie malnutrition, and required supervision and/or touching assistance for eating. A physician’s order specified a regular diet with dysphagia advanced texture and regular consistency. The facility’s menu and diet ticket for a lunch meal listed roasted Brussels sprouts that were to be served chopped for this dysphagia advanced diet. On the day of the incident, a CNA observed the resident during lunch rapidly shoving food into her mouth, not chewing, and pocketing food in her cheeks, which was unusual for the resident who typically fed herself slowly. The CNA moved the plate out of reach to slow the resident’s intake and address the food already in her mouth, then noted the resident’s lips turning bluish and believed she was choking. The CNA performed the Heimlich maneuver while the resident was seated, resulting in expulsion of a whole Brussels sprout, after which an LPN assumed care. The Corporate Risk Management Nurse later confirmed the resident had been served whole Brussels sprouts instead of chopped Brussels sprouts as required by the ordered dysphagia advanced diet and the facility’s texture policy.
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