Failure to Update Care Plan to Reflect Current Dietary Orders
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple medical diagnoses, including BPH, anxiety disorder, dysphagia, and dementia, to accurately reflect his current dietary needs. The resident's care plan, initiated in 2022, indicated a regular, mechanically soft diet with pureed meat texture and thin liquids due to swallowing difficulties. However, the active dietary order in the electronic medical record, dated later, specified a regular, mechanically soft diet with chopped meat texture. During observation, the resident was provided a meal with chopped meat consistency and consumed it without swallowing concerns, but the care plan was not updated to match this change. Interviews with nursing staff and administrative personnel confirmed that care plans are intended to be updated quarterly or as changes occur, and should accurately reflect each resident's current care needs, including diet type and consistency. The facility's policy requires comprehensive assessments and individualized interventions, with care plans reviewed and updated to reflect any changes. Despite these procedures, the resident's care plan was not revised to remove the therapeutic diet, resulting in a discrepancy between the care plan and the actual dietary order provided.