Failure to Update Care Plan for Diet Order Change
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's current dietary needs. Specifically, the care plan for a male resident with a history of brain cancer, hemiplegia, and aphasia did not reflect a physician-ordered change from a pureed diet to a mechanical soft diet, despite the order being in place and the resident receiving the correct diet during meal service. The resident was moderately cognitively impaired, dependent on staff for eating, and required a mechanically altered diet, as documented in his assessments and physician orders. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for updating care plans. The Dietary Manager updated the meal ticket but was unaware of the need to update the care plan, while the LVN who received the diet order acknowledged she should have updated the care plan. The MDS Coordinator, responsible for auditing care plans, was not aware of the Dietary Manager's role in care plan updates. The facility's policy required care plans to be updated as resident conditions changed, but this was not followed in this instance.