Failure to Include Dysphagia in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of the residents' needs, specifically omitting the diagnosis of dysphagia for two residents. Both residents had documented diagnoses of dysphagia oropharyngeal phase upon admission, but their care plans did not reflect this condition. The Minimum Data Set (MDS) assessments for both residents indicated varying levels of cognitive impairment and the need for supervision or assistance with eating, but did not note any signs or symptoms of swallowing disorders. Despite this, the care plans were not updated to include interventions or objectives related to dysphagia. Interviews with the Director of Nursing (DON) confirmed that dysphagia should have been included in the care plans, as it was present in the residents' diagnoses. The MDS coordinator stated that dysphagia was considered a therapy diagnosis and therefore was not added to the care plan, rationalizing that the residents' therapeutic diets addressed the issue. However, facility policy requires that care plans include measurable objectives and timetables to meet all resident needs, derived from comprehensive assessments. The omission of dysphagia from the care plans was identified through interviews and record reviews.