Failure to Develop and Implement Comprehensive Care Plan for Dysphagia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a diagnosis of dysphagia, as identified through a speech therapy evaluation. Despite the resident's medical history, which included kidney failure, difficulty walking, dementia, Parkinson's disease, stroke, and a history of stomach cancer, there was no documented diagnosis of dysphagia on the face sheet or in the Minimum Data Set (MDS). The resident's care plan did not address dysphagia or the need for crushed medications, even though the speech therapy assessment indicated the resident required a modified diet, swallowing precautions, and crushed medications due to difficulty swallowing. Observations and interviews revealed that the resident reported receiving crushed medications for swallowing difficulties but noted inconsistency in this practice. The speech pathologist confirmed the resident was on swallowing precautions and required a soft diet, thin liquids, alternating bites, crushed medications, and upright positioning during meals. The speech pathologist also stated that the resident's dysphagia and need for crushed medications should have been included in the care plan, and that it was nursing's responsibility to ensure this was addressed. The nurse practitioner acknowledged the resident's swallowing difficulties but deferred to speech therapy for medication orders. The MDS nurse, responsible for updating diagnoses and care plans, confirmed that the resident's dysphagia was documented in therapy notes but not reflected in the face sheet, MDS, or care plan at the time of the survey. The nurse stated that this omission could result in the resident not receiving proper care, as the care plan did not accurately reflect the resident's needs for swallowing precautions and medication administration. The facility's policy required comprehensive care plans to include measurable objectives and timeframes based on comprehensive assessments, which was not followed in this case.