Failure to Develop Comprehensive Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that addressed the specific feeding assistance needs for one of three residents reviewed. The resident in question was admitted with multiple diagnoses, including sequelae of cerebral infarction, dysphagia, need for assistance with personal care, tremors, neuropathy, and muscle weakness. Despite these conditions, a review of the resident's most recent care plan revealed no documented interventions for feeding assistance. Direct observation showed that the resident was entirely dependent on staff for feeding, with staff members providing all food and hydration without the resident's participation. Multiple interviews with CNAs, LPNs, and an occupational therapist confirmed that the resident required total assistance with feeding at all meals. The staff responsible for the resident's care plan acknowledged that feeding assistance interventions were not included and confirmed that they should have been. The Director of Nursing also confirmed that residents needing feeding assistance should have individualized interventions documented in their care plans to ensure proper care and support.