Failure to Update Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including Parkinson's disease, type 2 diabetes, hypertension, anxiety disorder, muscle weakness, and lack of coordination. The resident had moderate cognitive impairment and required setup or clean-up assistance for eating, as indicated in the quarterly MDS assessment. Despite a primary care provider order instructing staff to attempt feeding assistance and elevate the head of the bed during meals, the care plan was not updated to reflect the resident's need for feeding assistance. Observations showed the resident struggling to feed himself, with food spilling and difficulty getting food onto utensils during meals. Interviews with staff revealed a lack of awareness of the provider's order and a breakdown in communication regarding the resident's change in self-feeding ability. The MDS Coordinator was unaware of the order and stated it was the nurses' responsibility to inform her of such changes. Nursing staff acknowledged the resident's need for assistance and the importance of reporting changes to the care team for care plan revision. The facility's policy required care plan updates when there is a significant change in a resident's condition, but this was not followed, resulting in the resident's care plan not reflecting his current needs.