Failure to Timely Update Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, specifically omitting information regarding newly ordered tube feedings. The resident, a male with a history of muscle weakness, traumatic brain injury, and gastrostomy status, was admitted with severe cognitive impairment as indicated by a BIMS score of 3. Physician orders documented the initiation of Isosource tube feeding, and clinical notes confirmed administration began as ordered. However, review of the resident's care plan on multiple dates showed no inclusion of tube feeding information until several days after the order was implemented, despite the resident actively receiving tube feedings during this period. Interviews with facility staff revealed that the process for updating care plans involved multiple roles, including the MDS nurse, ADON, and Patient Care Coordinator, but there was a lack of timely interdisciplinary communication and action to ensure the care plan reflected the resident's current needs. The Director of Nursing acknowledged that the care plan should be updated promptly to guide staff in providing appropriate care and confirmed the delay in updating the care plan to include tube feeding instructions. Facility policy requires ongoing assessment and timely revision of care plans as resident conditions change, which was not followed in this instance.