Failure to Individualize Care Plan for NPO Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was NPO (nothing by mouth) and required enteral feeding. Despite the resident's medical history, which included Huntington's disease, diabetes, muscle wasting, hypoxia, and aphasia, and the fact that he was unable to eat or drink by mouth, his care plan and Kardex included an intervention for a bedtime snack. This intervention was not appropriate for his condition, as confirmed by multiple staff interviews and record reviews. Observations and interviews revealed that the resident had a feeding tube and was on continuous enteral feeding, with staff consistently aware that he could not have anything by mouth. The Kardex, however, still listed a bedtime snack as a task, which was an error resulting from an auto-populated field that was not removed for this resident. The MDS nurse acknowledged responsibility for ensuring individualized and accurate care plans and admitted to failing to remove the inappropriate task from the resident's Kardex. Documentation showed that CNAs had not provided a bedtime snack to the resident, as indicated by their documentation of 'NA' for the task. Both the MDS nurse and the DON confirmed that the task should have been removed from the Kardex for residents who are NPO, and that the error was due to a failure to update the care plan to reflect the resident's specific needs. The facility's policy requires care plans to be individualized and include measurable objectives and appropriate interventions based on the resident's assessment.