Failure to Update Care Plan Following Change in Diet Order
Penalty
Summary
The facility failed to review and revise the care plan for a resident after a change in dietary orders, as required. Record review showed that the resident, who had multiple diagnoses including dementia, dysphagia, COPD, peripheral vascular disease, obstructive uropathy, osteoarthritis, and depression, was admitted and readmitted with significant cognitive and physical impairments. The comprehensive MDS assessments indicated the resident required a mechanically altered diet, and physician orders dated 10/01/2025 specified a regular diet with pureed texture. However, the resident's care plan, last revised on 08/04/2025, continued to list a regular mechanical soft diet with thin liquids and was not updated to reflect the new pureed diet order. Observation confirmed that the resident was receiving a pureed diet, and the resident reported having received 'baby food' for some time. Interviews with the MDS nurse and DON revealed that care plan updates were the responsibility of the MDS nurse, who acknowledged ongoing updates to individual care plans. The DON and Administrator both stated that care plans should be updated as orders are received and reviewed quarterly, and that discrepancies between care plans and physician orders could result in harm. Facility policy requires care plans to be revised based on changing needs and current interventions, but this was not followed in this instance.