Care Plan Lacked Required Dietary Information
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's needs, specifically omitting the resident's mechanical soft texture diet. The resident, a male with diagnoses including unspecified dementia, seizures, muscle wasting and atrophy, lack of coordination, and muscle weakness, was dependent on staff for multiple activities of daily living and required a mechanically altered diet as indicated in his physician orders and MDS assessment. However, a review of the resident's care plan showed that it did not include the mechanical soft diet, despite this being ordered by the physician and provided during meal observations. Interviews with facility staff, including an LVN, the MDS Coordinator, and the Administrator, confirmed that the care plan should have reflected the resident's mechanical soft diet. The staff relied on meal tickets and physician orders to provide the correct diet but were unaware that the care plan was not updated accordingly. The facility's policy requires that care plans include measurable objectives and timeframes to meet residents' identified needs, but this was not followed in this instance, resulting in an incomplete care plan for the resident.