Failure to Develop Person-Centered Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to develop a person-centered care plan addressing feeding assistance for one resident. According to facility policy, a comprehensive care plan with measurable objectives and timetables should be developed and implemented for each resident, including support for activities of daily living such as dining. Review of the resident's medical record showed diagnoses including dysphagia, senile degeneration of the brain, anorexia, moderate protein calorie malnutrition, and sequelae of intracerebral hemorrhage. The resident was rarely or never understood, had an altered level of consciousness, and required moderate assistance with eating, as well as being dependent for personal hygiene, mobility, and transfers. A grievance filed by the resident's family member reported that a lunch tray was left on the bedside table and had tumbled onto the resident's bed, with no aide present in the room. Investigation confirmed the tray was left in the room over the resident. Review of the resident's care plan revealed it did not reflect the required level of feeding assistance. During interviews, staff confirmed that the resident required staff assistance to be fed and acknowledged that this need was not included in the care plan, despite it being necessary.