Failure to Provide Ordered Thickened Liquids and Adequate Hydration
Penalty
Summary
The facility failed to ensure residents received liquids consistent with their ordered altered consistencies and hydration needs. One resident with post-stroke swallowing difficulties, cognitively intact per an admission MDS, was observed with an untouched lunch tray that had no fluids. The resident had chapped lips and dry facial skin and reported that meals had been cold and unpalatable since admission, describing breakfast as a glob of eggs and an unmanageable muffin, and receiving dry cereal without milk on two mornings. A CNA, upon checking the diet slip, noted it stated no drinks on the tray and did not know what that meant, indicating they would need to ask the nurse. An LPN then reviewed the orders and identified that the resident required Level 2 (nectar thick) liquids, retrieved a single carton of nectar thick juice from a locked nourishment room, and provided it, with no other Level 2 beverages observed in the refrigerator. The LPN stated that aides would need to ask the nurse to know what type of liquid to give a resident. Another resident, also admitted with post-stroke swallowing difficulties and cognitively intact per the admission MDS, had a dietary order for Level 2 liquids. During a meal observation, this resident’s tray diet slip contained no information about liquid textures, and the tray included two containers of normal-consistency juice. Later, the resident was observed in bed drinking normal-consistency cranberry juice and reported that aides bring juice containers upon request, expressing dislike for nectar thickened fluids, especially water, but acknowledging not getting enough fluids. The Registered Dietician/Kitchen Manager stated that all residents should receive sufficient fluids of the correct consistency, that residents with altered fluid consistency should be monitored for compliance and hydration, and that there should be a quick reference system to communicate residents’ fluid consistency needs to floor staff. The report states that these failures placed residents at risk for dehydration, aspiration, and decreased quality of life.
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