Failure to Develop Comprehensive Care Plans for Food Preferences and Allergies
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by federal regulations. Specifically, two residents who expressed a preference for Korean food at lunch and dinner did not have care plans reflecting these preferences. Instead, both residents were observed receiving pureed American food items, despite their nutrition progress notes and lunch tickets indicating a preference for Korean cuisine. The Director of Social Services (DSS) confirmed that the care plans for these residents did not address their food preferences. Additionally, another resident with a documented food allergy to shrimp did not have a care plan problem developed to address this allergy. The resident's admission record clearly indicated the shrimp allergy, but a review of the care plan showed no documentation or interventions related to this allergy. This was verified by an LVN, who acknowledged the absence of a care plan addressing the allergy. These deficiencies were confirmed through medical record reviews, direct observations of meal service, and staff interviews. The Director of Nursing (DON) was informed of these findings and acknowledged the lack of appropriate care planning for the residents involved.
Plan Of Correction
Date of compliance: 7/2/2025 F656 Develop/Implement Comprehensive Care Plan Corrective action for residents found to have been affected by this deficiency: - Residents 40, 27, and 96 nutrition care plans were updated by the Dietary Supervisor (DS) and Assistant Director of Nursing (ADON) on 6/18/25. Specifically, Resident 40's care plan addresses the shrimp food allergy, and for Residents 27 and 96, their dietary preference for Korean food. Corrective action for residents that may be affected by this deficiency: - The DS and ADON audited the nutrition care plans on 6/18/25 and completed on 7/9/25, to ensure all care plans capture food allergies and preferences for Korean food. - The Director of Nursing (DON) and ADON in-serviced nursing, the RD and DS utilizing P&P "Comprehensive Care Plans" initiated on 6/23/25 and completed on 7/9/25, emphasizing the importance of ensuring all nutrition care plans address food allergies and cultural food preferences. Measures that will be put into place to ensure that this deficiency does not recur: - The RD, DS, ADON, or trained designee will conduct nutrition care plan audits weekly X 3 months to ensure care plans address food allergies and food preferences. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - The DS, RD, or ADON will report their findings regarding Comprehensive Care Plans to the QA committee for discussion and further recommendations. The QA will continue monitoring for at least 3 months or until substantial compliance is achieved. Date of compliance: 7/9/25 Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: - The DS, RD, or ADON will report their findings regarding Comprehensive Care Plans to the QA committee for discussion and further recommendations. The QA will continue monitoring for at least 3 months or until substantial compliance is achieved.