Failure to Accurately Document and Update Medical Records for Diet Orders
Penalty
Summary
The facility failed to maintain accurate medical records and documentation in accordance with professional standards for a resident with a physician's order for aspiration precautions. The resident, who had diagnoses including Alzheimer's disease and a history of dysphagia, was readmitted with an order for aspiration precautions such as head of bed elevation, staff assistance during meals, oral care after eating, nectar thick fluids, and a puree diet. Subsequently, a new physician's order was issued for a regular house diet with thin liquids. Despite this change, the Treatment Administration Record (TAR) continued to reflect that aspiration precautions were being implemented and signed off as completed three times daily, even after the new diet order was in place. Surveyor observation revealed the resident eating alone with thin liquids and a regular diet, contrary to the previous aspiration precautions. Interviews with staff confirmed that the order for aspiration precautions was no longer active, yet documentation on the TAR indicated otherwise. One LPN acknowledged signing off on the aspiration precautions without verifying the current diet order, and the Director of Nursing Services stated that staff are expected to document accurately. This discrepancy between actual care provided and documentation led to the deficiency.