Failure to Develop Individualized Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the tube feeding needs of a resident with multiple complex medical conditions. The resident was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, type 2 diabetes mellitus, gastrostomy, dysphagia, gastro-esophageal reflux disease, and muscle weakness. The resident's Minimum Data Set indicated moderate cognitive impairment and that eating ability was not assessed due to medical or safety concerns. Despite having physician orders for enteral feeding via gastrostomy tube, the care plan did not appropriately address the resident's tube feeding requirements. During interviews and record reviews, staff, including an LVN and the DON, were unable to locate a comprehensive care plan specifically addressing the resident's tube feeding. The care plan on file only referenced the presence of a gastrostomy tube, without detailing the necessary care and feeding protocols. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, but this was not in place for the resident's tube feeding at the time of the survey.