Failure to Develop and Implement Person-Centered Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed all identified needs for a resident with complex medical conditions. Specifically, the care plan did not include the resident's requirement for G-J tube feeding with small amounts of pureed textured snacks for pleasure, to be administered under the supervision of a Speech-Language Pathologist (SLP) or a trained caregiver. This omission was identified despite the resident's comprehensive assessment and physician orders clearly indicating the need for such interventions. The care plan also did not reflect the resident's G-J tube status or the specific feeding protocols outlined in the hospital discharge summary and physician orders. The resident in question was an elderly female with multiple diagnoses, including gastronomy status, dyskinesia of the esophagus, dysphagia (pharyngeal phase), metabolic encephalopathy, and acute pulmonary edema. Her admission Minimum Data Set (MDS) assessment indicated severe cognitive impairment and that eating was not attempted due to medical or safety concerns. Although the Care Area Assessment (CAA) triggered the need for care planning related to feeding tube care, the actual care plan failed to address the resident's specific nutritional and feeding needs as documented in her medical records and physician orders.