Care Plans Did Not Reflect Physician-Ordered Diets
Penalty
Summary
The facility failed to ensure that the individualized comprehensive care plans accurately reflected the current physician-ordered diets for three residents. For one resident with severe cognitive impairment and multiple diagnoses, the care plan listed a regular diet instead of the physician-ordered vegetarian diet. Another resident, who was cognitively intact and had chronic conditions, had a care plan that did not specify the required chopped texture diet as ordered by the physician, instead listing a regular texture. A third resident with severe cognitive impairment and neurological diagnoses had a care plan that did not reflect the physician-ordered pureed texture, instead listing a ground texture. These discrepancies were confirmed through record reviews and staff interviews. The Registered Dietician acknowledged responsibility for creating accurate nutritional care plans and confirmed that the care plans did not match the physician orders for the affected residents. The Director of Nursing also confirmed that care plans should match physician orders and emphasized the importance of accuracy to prevent adverse outcomes. The facility's policy requires that care plans describe the services to be furnished to attain or maintain the resident's highest practicable well-being.