Failure to Update and Implement Comprehensive Care Plans for Oral Hygiene and Dietary Changes
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to oral care, hygiene, and dietary needs. For one resident with multiple sclerosis, neuropathy, seizures, and functional quadriplegia, the care plan did not address oral care, hygiene, or the resident's refusal of these activities. Observations revealed food particles and debris in the resident's mouth, and interviews confirmed that oral care was not being provided daily. The resident was dependent on staff for all activities of daily living and had impaired cognitive skills, yet the care plan lacked specific interventions for oral hygiene and refusal of care. Another resident, diagnosed with metastatic breast cancer, seizures, urinary tract infection, and muscle weakness, experienced a change in condition that required a switch from a regular to a puree diet and the need for a one-on-one feeder. Despite these significant changes, the resident's care plan was not updated to reflect the new dietary requirements or the need for individualized feeding assistance. Observations confirmed that the resident was being fed by a certified nursing assistant and required extra time to swallow, but these interventions were not documented in the care plan. Interviews with nursing staff and the Director of Nursing confirmed that care plans should be updated to reflect changes in condition, refusals of care, and specific interventions such as oral hygiene and dietary modifications. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but these requirements were not met for the two residents in question.