Failure to Update Care Plans for Utensil Use
Penalty
Summary
Staff failed to update and revise care plans for two residents to reflect their current needs regarding the use of appropriate utensils during mealtime. For one resident with unspecified dementia and muscle weakness, the care plan indicated the use of plastic utensils due to a history of suicidal thoughts, but the resident was observed eating with a metal fork. The Administrator confirmed that the resident was now permitted to use metal utensils, but the care plan had not been updated to reflect this change. Both the Administrator and the DON acknowledged that care plans were not revised as required, despite their expectation for quarterly reviews and updates. For another resident with dementia on a pureed diet due to choking issues, the care plan directed staff to provide a small spoon and specific assistance during meals. However, the resident was observed eating with a regular-sized teaspoon, and the Speech-Language Pathologist stated that the resident managed well with the pureed diet and could use a regular spoon. The Administrator and DON both confirmed that the care plan was not updated to reflect the change in utensil use after the diet modification, and the spoon directive was missed during care plan reviews.