Failure to Develop Comprehensive Care Plans for Swallowing Strategies and C-PAP Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents in the areas of swallowing strategies and c-pap use. For one resident with a complex medical history including cerebrovascular disease, dysphagia, and dementia, the medical record and speech therapy (ST) assessments recommended specific swallowing strategies such as a pureed diet with thickened liquids, no straws, small bites, and upright posture during meals. However, the resident's care plan did not include these individualized swallowing recommendations, despite documented weight loss and ongoing nutritional concerns. This omission was confirmed by facility staff during interviews. For another resident with multiple diagnoses including obstructive sleep apnea and a history of orthopedic aftercare, the care plan did not address the use of a c-pap machine. There were no physician orders for the c-pap, and observations revealed the c-pap mask was left on the floor under the bed without a protective bag. The absence of a care plan for c-pap use was confirmed by facility staff. Facility policy requires a comprehensive care plan to be developed within 21 days of admission and updated as the resident's condition changes. In both cases, the facility did not ensure that the care plans reflected the residents' current needs and recommendations, as evidenced by the lack of documented swallowing strategies and c-pap use in the respective care plans.