Failure to Update Care Plan After Change in Nutritional Status
Penalty
Summary
The facility failed to revise and update the care plan to reflect the current status of a resident who had experienced significant changes in nutritional management. The resident, who had a history of stroke, quadriplegia, dysphagia, protein-calorie malnutrition, and anemia, was initially admitted with a feeding tube in place. Documentation showed that the feeding tube was removed, and the resident was transitioned to a regular, pureed, honey-thick diet, with the patient or guardian declining replacement of the tube. Despite these changes, the care plan continued to reference tube feeding and NPO status, with goals and interventions that were no longer applicable to the resident's current condition. Interview with an LPN confirmed that the resident had not received food or fluids through a PEG tube for several months. Review of the care plan revealed it still included interventions for tube feeding and NPO status, rather than reflecting the resident's current oral intake and dietary needs. The facility's own policy required care plans to be revised with changes in condition, but this was not done in this case, resulting in a care plan that did not accurately represent the resident's current nutritional status or care requirements.