Failure to Update and Implement Comprehensive Care Plans for Eating Assistance
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified deficits in activities of daily living (ADLs), specifically related to eating. For one resident with type 2 diabetes and moderate cognitive impairment, the care plan did not include interventions for eating assistance, despite the resident requiring set up or clean-up help as documented in the admission MDS assessment. Observations confirmed the resident struggled to remove plastic coverings from food items, and staff interviews indicated that assistance was needed but not formally documented in the care plan. For another resident with hemiplegia following a stroke and moderate cognitive impairment, the care plan also lacked interventions for eating, even though the resident required substantial or maximal assistance and needed to be fed, as indicated in the MDS assessment. Staff interviews revealed that knowledge of these needs was communicated informally rather than through updated care plans or the Kardex, which is used by CNAs to guide care. The facility's policy required care plan revisions upon status change, but this was not followed, resulting in incomplete documentation of the residents' care needs.