Failure to Update Care Plan for Physician-Ordered Diet Changes
Penalty
Summary
The facility failed to update the care plan to reflect the current diet as ordered by the physician for a resident with vascular dementia and dysphagia. The resident was admitted with moderate cognitive impairment and required partial to moderate assistance with eating. The care plan, last revised on 4/23/25, indicated a regular diet with thin liquids, but did not reflect subsequent changes in the physician's orders. On 05/27/25, the physician ordered a mechanical soft diet with nectar thick liquids due to overt signs and symptoms of aspiration, and on 05/28/25, pureed meats were added to the diet order. Despite these changes, the care plan was not updated to reflect the new dietary orders. The Speech Therapist evaluated the resident and recommended the diet downgrade due to high risk for aspiration, and both the MDS Coordinator and DON confirmed that the care plan should have been updated. The MDS Coordinator was unaware of the changes to the diet orders and acknowledged responsibility for updating care plans, indicating a lapse in communication and care plan revision processes.