Failure to Update Care Plans for Thickened Liquids
Penalty
Summary
The facility failed to review and revise care plans for three residents after their comprehensive assessments, specifically neglecting to update the care plans to reflect physician orders for thickened liquids. For each of the three residents, medical records indicated diagnoses including dysphagia and orders for thickened liquids, as documented in their quarterly MDS assessments and monthly physician orders. However, the care plans for these residents were not updated to include these dietary modifications. Interviews with facility staff confirmed that the MDS nurse had not updated the care plans due to not reviewing the residents' physician orders. The DON also acknowledged that the care plans should have been updated to reflect the thickened liquids orders. Facility policy requires care plans to be reviewed and updated at least quarterly and with significant changes in condition, but this was not done for the affected residents.