Failure to Update Care Plan with Swallowing Safety Interventions
Penalty
Summary
The facility failed to update and implement a comprehensive care plan to address a resident's swallowing difficulties and risk of choking, despite multiple documented incidents and professional recommendations. The resident had a history of unspecified tremor, partial digestive tract removal, oropharyngeal dysphagia, and cognitive impairment, and required set-up assistance with meals. Although the resident was observed to have difficulty swallowing medications, resulting in coughing and choking episodes, the care plan only included a general intervention for eating set-up and did not reflect the specific risks or interventions needed for safe swallowing. Speech therapy evaluated the resident and provided detailed recommendations, including crushing medications, upright positioning during and after meals, slow eating, small bites and sips, thorough chewing, and specific swallowing techniques. These recommendations, as well as the physician's order to crush medications, were not incorporated into the resident's care plan or the nursing assistant care guide. Interviews with staff and family confirmed awareness of the resident's swallowing issues and the education provided, but the care plan remained incomplete, lacking the necessary interventions to address the identified risks.