Failure to Initiate NPO Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan reflecting a resident's current therapeutic diet order of nothing by mouth (NPO), as required by facility policy. The resident was admitted with diagnoses including adult failure to thrive and Alzheimer's disease, and a physician's order was in place for NPO status due to the resident's inability to swallow food or medications. Despite this, a review of the resident's active care plans showed no documentation or care plan addressing the NPO order. Interviews with both a registered nurse and the Director of Nursing confirmed that the resident's NPO status was not included in the care plan, even though the resident was at high risk for aspiration if given food or fluids by mouth. The facility's policy required that a comprehensive, person-centered care plan, including physician and dietary orders, be developed and implemented within 48 hours of admission, but this was not done for the resident in question.