|TO:||DDS Regional Directors, STS Director, Private Providers, CO Quality Management Personnel|
Lakisha Hyatt, Director of Health and Clinical Services
Daniel A. Micari, Director, Quality Management Services
|DATE:||May 13, 2013|
|RE:||Safety Alert Directive: Adherence to Correct Liquid Consistency for Individuals with Modified Diets|
This Safety Alert is to bring immediate attention to a concern which exists throughout our entire service delivery system regarding not adhering to a prescribed liquid consistency. There have been recent incidents of inappropriate consumption of the thin liquid Jell-O by individuals with a modified liquid consistency. Over the course of nine months there have been three fatalities involving Jell-O consumption and aspiration. For each of the cases, the individual had a prescribed modified nectar liquid consistency.
Outlined below are essential safety precautions for all individuals for whom the department bears direct or oversight responsibility for their health and safety. Agency protocols must ensure the following:
Direct care providers are informed that Jell-O is a thin liquid and should never be administered to an individual requiring a modified liquid consistency.
All staff shall receive the dysphagia training upon hire and every two years thereafter.
Verification of dysphagia training and implementation of the appropriate choking prevention strategies shall be documented and available on-site at the service location.
All agencies must have written defined processes for communicating diet modifications in such a way that care providers can easily obtain the information.
Joseph Drexler, Deputy Commissioner
Quality Management Services Staff
Health and Clinical Services Staff