Failure to Update Care Plan for Dietary Changes
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple medical diagnoses, including benign prostatic hyperplasia, anxiety disorder, dysphagia, and dementia, to accurately reflect his current dietary needs. The resident's care plan, initiated in 2022, continued to indicate a regular, mechanically soft diet with pureed meat texture and thin liquids, despite an active dietary order from May 2025 specifying a regular, mechanically soft diet with chopped meat texture. Observations confirmed that the resident was provided and consumed a chopped meat consistency meal without swallowing concerns, but the care plan was not updated to match this change. Interviews with nursing staff and administrative personnel revealed that care plans were intended to be updated quarterly or as changes occurred, and that all staff had access to view and review these plans. The facility's policy required care plans to be individualized and updated to reflect any changes in the resident's goals and care needs. However, the failure to revise the care plan to remove the therapeutic diet and accurately document the current dietary order resulted in a discrepancy between the resident's actual care and the documented plan.