Failure to Develop and Implement Dysphagia Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with dysphagia, as required by federal regulations. Both residents had documented diagnoses including acute respiratory failure with hypoxia and orders for nectar-thick liquids to address their swallowing difficulties. Despite these orders, one resident was observed drinking regular water and another was observed drinking unthickened hot chocolate, both contrary to their prescribed diet orders. The Activity Director and Director of Nursing confirmed that the drinks should have been thickened according to the residents' meal tickets to prevent choking or aspiration. Further review of the electronic medical records for both residents revealed no documented evidence of a dysphagia care plan. This was confirmed by both a licensed nurse and the Director of Nursing, who acknowledged that a care plan should have been in place as a means of communication for nursing staff. The facility's own policy requires the development and implementation of a comprehensive, person-centered care plan for each resident, including all services identified in the comprehensive assessment.
Plan Of Correction
Either by the governmental agencies or third party. Any changes to provider policy or procedures should be considered to be subsequent remedial measures as that concept is employed in Rule 407 of the federal rules of evidence and California evidence code section 1151 and should be inadmissible in any proceeding on that basis. F656 Develop/Implement Comprehensive Care Plan How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) On 04/09/25 Resident 49 and Resident 79 care plans were updated to include dysphagia diagnosis. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Clinical Resource Nurse completed an audit on 05/01/2025 to ensure all current residents with a dysphagia diagnosis/diets had a completed care plan to reflect their dysphagia diagnosis. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) An in-service was initiated by facility DON on 04/11/2025 to LN staff regarding the importance of completing dysphagia care plans for residents with a dysphagia diagnosis. d) Medical Records / designee will pull the report of new admissions each morning and bring to the clinical meeting 5 days per week to ensure dysphagia care plans have been completed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) Medical Records / designee will pull the report of new admissions and bring to the clinical meeting 5 days per week to ensure dysphagia care plans have been completed. Any issues identified during the audit will be brought forth to the IDT members and physician for review and resolution. All non-compliance issues identified will be brought forth immediately and reported to the IDT members for review, validation and resolution. DON / designee will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations. F 656