Failure to Maintain Comprehensive, Person-Centered Care Plan After Hospitalizations and Diet Changes
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple complex medical conditions. The resident, an elderly female, had numerous diagnoses including lobar pneumonia, acute kidney failure, gout, mononeuropathy, diabetes, malignant neoplasm, metabolic encephalopathy, anemia, stage 4 chronic kidney disease, MRSA pneumonia, and malnutrition. Her 5-day admission MDS showed a BIMS score of 5 indicating severe cognitive impairment, range of motion impairment, wheelchair use, need for supervision or touching assistance with eating, and a mechanically altered/therapeutic diet with high-risk medications. She also had orders for skilled speech therapy for cognitive-linguistic deficits and dysphagia management, and a speech-language pathology screening documented signs of swallowing impairment and the need for a mechanically altered diet. Despite these identified needs, record review showed that the resident’s care plan contained only two focus areas: pressure ulcer risk and antibiotic therapy, initiated in December. The care plan did not address dysphagia, aspiration risk, supervision during meals, respiratory issues, or treatments related to pneumonia, nor did it reflect her textured diet orders, aspiration precautions, or additional antibiotic treatment following hospitalization for pneumonia and subsequent readmission. Physician orders documented a low-concentrated sweets/no added salt diet with ground texture and thin liquids, and nephrology notes documented a hospitalization for right lower lobe pneumonia with antibiotic treatment and an ordered textured diet, but these changes and risks were not incorporated into the care plan. Interviews with the RNC, DON, and the MDS nurse revealed that the MDS nurse was responsible for initial care plan development and updates, and that acute care plans were expected to be completed immediately upon readmission with new conditions or concerns. The RNC and DON stated that the resident had not been continuously in the facility for 21 days to trigger a comprehensive care plan and that during the relevant period there was no MDS nurse for about a month, resulting in a backlog despite some corporate assistance. The MDS nurse described the expected process for post-hospital discharge review, including morning meetings to capture changes such as hospitalizations, diet changes, therapy referrals, and emerging risks, and confirmed that repeat hospitalizations, pneumonia, swallowing risks, diet downgrades, antibiotic use, and decline should be reflected in the care plan. The facility’s written policy required a comprehensive, person-centered care plan with measurable objectives and timetables for each resident and mandated IDT review and updates with significant changes in condition and upon readmission, but these requirements were not met for this resident.
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