Failure to Update Care Plan Following Diet Change
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect a change in diet from nothing by mouth (NPO) to a pureed diet. The resident, who had a history of protein-calorie malnutrition and dysphagia, was initially admitted with orders for NPO status and tube feeding. Despite subsequent changes in the resident's dietary orders, including the introduction of a pureed diet and honey thickened liquids, the care plan continued to include outdated interventions and need statements referencing NPO status and tube feeding. Observations confirmed that the resident was receiving a pureed diet, yet the care plan was not consistently updated to reflect this change. Interviews with facility staff, including the MDS nurse, DON, and Administrator, revealed that care plans were expected to be updated in real time and during regular reviews, but this did not occur for the resident in question. The facility's policy required care plans to be individualized and updated with significant changes, but the care plan for this resident retained obsolete information and did not accurately communicate the current dietary needs to staff. This failure was identified through record review, staff interviews, and direct observation of the resident receiving oral nutrition.