Failure to Follow Ordered Pureed Diet and Supervision Requirements for Dysphagic Resident
Penalty
Summary
The facility failed to ensure that food items were provided according to physician-ordered diet textures for a resident with dysphagia and severe cognitive impairment. The resident had multiple diagnoses including hemiplegia, dementia, type 2 diabetes mellitus, chronic kidney disease, and dysphagia, and was care planned for a high-protein, pureed diet with nectar-thick liquids, along with direct 1:1 supervision, small bites, slowed rate of intake, and alternating food and fluids every few bites. Physician orders specified a high-protein, pureed texture diet with nectar consistency and direct one-to-one supervision during intake due to a history of suspected aspiration/penetration episodes. Despite these orders and care plan interventions, a CNA provided the resident with a whole banana, which did not conform to the ordered pureed texture and was given without the required direct supervision by the speech therapist. Multiple staff statements and interviews confirmed that the CNA had a pattern of serving residents food items not consistent with their diet orders and that she had given this resident a whole banana. The CNA reported she believed she had approval from the speech therapist to provide such items if the resident was awake and alert, but the speech therapist denied ever authorizing the resident to receive a banana without his direct supervision. The speech therapist acknowledged he did not assess the resident after learning of the incident and only reported it to a nursing supervisor. Further review of the medical record and nursing documentation showed there was no respiratory assessment completed for the resident after receiving the incorrect food texture. The facility’s dysphagia policy required food service and nursing staff to follow written diet and fluid consistency orders, but this was not followed in this case.
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