Inaccurate Documentation of Nutritional Care Plan
Penalty
Summary
The facility failed to accurately document a nutritional care plan for a resident, identified as Resident #31, which led to a discrepancy between the care plan and the physician's order. The resident was observed receiving tube feeding at a rate of 50 milliliters per hour, consistent with the physician's order for Jevity 1.5. However, the care plan inaccurately listed Isosource 1.5 as the prescribed formula, which was not updated to reflect the current physician's order. The resident, who was initially admitted and later readmitted to the facility, has a diagnosis that requires attention to nutritional and hydration needs. The resident is severely dependent on assistance for activities of daily living and requires tube feeding as part of their care. The physician's order specified Jevity 1.5 at 50 ml/hr for 20 hours, with specific times for the feeding to be turned off and on. Despite this, the care plan was not updated to match the physician's order, leading to a discrepancy in the documented care plan. During an interview, a dietary technician acknowledged the oversight, stating that the care plans are updated quarterly or when changes occur, but admitted to forgetting to update the care plan in this instance. The facility's policy requires comprehensive, person-centered care plans that are revised as residents' conditions change, but this was not adhered to in the case of Resident #31, resulting in the documented 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 jevity 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 of 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.