Failure to Update Care Plan After Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident with a history of dysphagia, chronic kidney disease, muscle weakness, type 2 diabetes mellitus, and cognitive communication deficit was reviewed and revised by the interdisciplinary team following a significant change in condition. After the resident experienced a choking incident during a meal, which resulted in emergency intervention and hospitalization, the physician ordered a change in the resident's diet from Level 6 soft and bite-sized to Level 4 pureed. Despite this change, the resident's care plan was not updated to reflect the new dietary order. Record review showed that the care plan continued to list the previous diet and did not incorporate the updated pureed diet or address the recent choking event. Interviews with staff confirmed that the care plan had not been revised as required, and the DON acknowledged that nursing staff were responsible for updating the care plan but could not explain why it had not been done. The facility's policy requires care plans to be reviewed and revised after changes in a resident's condition, but this was not followed in this case.