Failure to Revise Care Plan for Swallowing Difficulties
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised to reflect the resident's current care needs and interventions following a change in condition. Specifically, after the resident experienced difficulty swallowing medication and coughed when taking sips of water, the care plan was not updated to address these new swallowing problems. The facility's policy required documentation of changes in condition and updates to the care plan as indicated, but this was not followed in this case. Medical record review showed that the resident had severe cognitive impairment, as indicated by a BIMS score of three, and was observed to cough after attempting to swallow a whole medication tablet with water. The medication was subsequently crushed, but the care plan was not revised to reflect this intervention or the resident's new swallowing difficulties. The Director of Nursing confirmed that the care plan should have been updated to address the resident's change in condition.