Failure to Ensure Ordered Nectar-Thick Liquids and Follow-Up on Outside Food
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively impaired resident consistently received nectar-thick liquids as ordered and to implement interventions to prevent the resident from receiving liquids inconsistent with the prescribed diet. The resident had diagnoses including metabolic encephalopathy, dysphagia (oral phase), and unspecified dementia with severely impaired cognitive skills for daily decision making, as documented on the quarterly MDS. Physician orders specified a regular diet with pureed texture and nectar (mildly thick) liquids, and the care plan identified a risk for aspiration related to dementia and the resident’s preference not to be assisted during meals, with interventions including monitoring for aspiration signs and providing thickened liquids as ordered. On a documented date, the resident’s family member brought an outside smoothie into the facility and asked RN #1 if it was acceptable to give it to the resident. RN #1 informed the family member that the resident was supposed to receive nectar-thick liquids, but the family member stated that the smoothie looked acceptable and that the resident would only have a taste. The progress note recorded that the smoothie cup contained approximately 45 cc (1.5 oz) of smoothie and that RN #1 did not witness the smoothie being given to the resident. There was no documentation that RN #1 followed up with the family member to determine whether the smoothie was actually given or how much was consumed. The record review and interviews further showed that there was no incident/accident report completed for this event, and no documentation that the physician was notified of the potential administration of an inappropriate fluid consistency, despite facility policy requiring all incidents and accidents to be reported to the nursing supervisor and the attending physician. The DON and UM acknowledged that the family member should have been educated, the physician notified, and the care plan updated with new interventions related to outside food, but these actions were not taken. The facility also did not implement measures to prevent recurrence of similar incidents involving outside food inconsistent with ordered diet and fluid thickness.
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