||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
||May 13, 2013|
||Safety Alert Directive: Adherence to Correct Liquid Consistency for Individuals with Modified Diets|
Safety Alert Directive
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.
As stated in Health Standard #07-1: Dysphagia and Swallowing Risks, Attachment F,
DDS has clearly defined liquid consistencies which identify Jell-O as a thin liquid, “Thin: includes all liquids, Jell-O, sherbet, Italian Ice and ice cream…..” http://www.ct.gov/dds/cwp/view.asp?a=2042&q=392872
In addition to the aspiration risk associated with Jell-O given to someone requiring a thickened liquid consistency, Jell-O also has high motility. This requires the ability of an individual to control the Jell-O once placed in their mouth. This requires careful consideration and an added degree of caution with Jell-O use..
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.
Below are dysphagia related resources available on the DDS website:
Preventing aspiration pneumonia:
Health Standard #07-1: Dysphagia and Swallowing Risks:
Dysphagia education sheet:
Any questions regarding the above should be referred to Lakisha Hyatt, Director, Health and Clinical Services, Lakisha.Hyatt@ct.gov
or Daniel Micari, Director, DDS Quality Management Services at Daniel.Micari@ct.gov
C: Terrence W. Macy, Ph.D., Commissioner
Joseph Drexler, Deputy Commissioner
Quality Management Services Staff
Health and Clinical Services Staff