Failure to Develop and Implement Person-Centered Care Plan for Resident with Feeding Tube
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a male resident who was admitted with diagnoses including unsteadiness on his feet and dysphagia. The resident was severely cognitively impaired, as indicated by a BIMS score of 0 out of 15, and had a feeding tube due to difficulty swallowing and refusal to eat or drink. Despite these significant care needs, a review of the resident's care plan revealed that there was no focus area or interventions documented for the feeding tube. Interviews with staff confirmed that the resident had a history of aspiration pneumonia and multiple hospitalizations, yet the necessary care planning was not completed. Further interviews with the DON revealed an awareness that care plans were not being developed, implemented, or revised as required. The facility's policy mandates the creation of a baseline care plan within 48 hours of admission, including all necessary interventions and measurable goals, and requires ongoing updates based on changes in the resident's condition. However, these procedures were not followed for this resident, as evidenced by the lack of a person-centered care plan addressing the feeding tube and related risks.