Inaccurate Documentation of Nutritional Care Plan
Penalty
Summary
The facility failed to accurately document a nutritional care plan for a resident receiving tube feeding. During observations, it was noted that the resident was receiving Jevity 1.5 at a rate of 50 ml/hr via a PEG tube, as per the physician's order. However, the care plan, which was revised in February 2025, incorrectly listed Isosource 1.5 as the tube feeding formula. This discrepancy between the care plan and the physician's order was confirmed during an interview with the dietary technician, who admitted to forgetting to update the care plan. The resident involved was severely cognitively impaired and dependent on assistance for activities of daily living, including feeding via a PEG tube. The resident's care plan was supposed to address potential nutritional and hydration deficits, but it failed to reflect the current physician's order for the tube feeding formula. The facility's policy requires that care plans be comprehensive and person-centered, with revisions made as the resident's condition changes. However, the dietary technician did not update the care plan to reflect the change in the tube feeding formula, leading to the deficiency.
Plan Of Correction
F842 Residents Records Identifiable Information CFR(s): 483.20(f)(5), 483.70(h)(1)-(5) Plan for specific resident: Dietary technician updated the care plan (Resident #31) on , technician adjusted the formula longevity 1.5 to ensure facility is in compliance. Quality Assurance Coordinator along with interdisciplinary team conducted a review on showing that (Resident #31) required an update in resident care plan. The care plan was updated and revised to include the current condition of (Resident #31) and necessary interventions. Interdisciplinary care plan team will focus on updating resident's care plan as needed or when a change of order is being received. To ensure a care plan is in place and that residents do receive treatment and care in accordance with professional standards of practice. Method to assume compliance for other residents: On Administrator provided in-service to the interdisciplinary team on the process of revising and updating the care plan based on assessment findings. As of Quality Assurance Coordinator along with interdisciplinary care plan team will review all orders when provided, when care plan is needed or when there is a change in residents care plan intervention. Interdisciplinary team will make proper adjustments to ensure 100% compliance with adequate monitoring and assessment. Findings will be presented to the administrator and DON monthly during Risk management meeting to evaluate the need for further intervention. System: As Quality Assurance Coordinator along with interdisciplinary care plan team will conduct internal audits on a weekly basis to ensure facility is updating all aspects of the resident's care plan including any type of intervention or physician's orders. The Audit will consist of a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical and functional needs. Quality assurance coordinator along with interdisciplinary team will ensure that residents care plan along with assessments are ongoing and that care plans must be revised as residents' information do change. Monitoring: As of Quality assurance coordinator along with interdisciplinary team will monitor residents care plan for 90 days on a weekly basis or as needed. The facility will maintain clinical records on each resident in accordance with accepted professional standards and practices, which will be completed, accurately documented, readily accessible, and systematically organized to ensure residents plan of care are being audited on a timely basis.