Failure to Update Care Plan and Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including dementia, Parkinson's disease, hemiplegia, and respiratory failure, was positioned appropriately in his Broda chair while being assisted with eating. The resident had recently transitioned from being NPO and dependent on tube feeding to receiving a mechanical soft diet with max assistance, in addition to continued enteral feedings. Despite physician orders specifying that the resident should be upright in the wheelchair during meals and remain upright for 30 minutes post intake, observations showed the resident was reclined back in his Broda chair during meal assistance on multiple occasions. The resident's care plan was not updated in a timely manner to reflect the new dietary orders and positioning requirements. The care plan continued to direct staff to provide tube feedings and water flushes, but lacked revised interventions for the current nutrition/eating order, including the need for upright positioning during oral intake. Staff interviews revealed uncertainty about whether the care plan had been updated to include the new diet and positioning interventions, and the MDS coordinator or nurses were identified as responsible for ensuring care plan updates following status changes. Facility policy required that the comprehensive care plan be reviewed and revised upon a change in resident status, with the interdisciplinary team collaborating on new interventions. However, the lack of timely care plan revision and failure to direct staff on the resident's current dietary and positioning needs resulted in the resident being assisted with eating while not properly positioned, contrary to physician orders and best practices for safe swallowing.