Incomplete Comprehensive Care Plans for Therapeutic Diets
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive, person-centered care plans were completed, and reviewed and revised by the interdisciplinary team to reflect current needs, specifically related to therapeutic diets for two residents. For Resident #1, a male with muscle wasting and atrophy, hypothyroidism, hypotension, and type 2 diabetes, the Initial MDS assessment documented that he was cognitively intact with a BIMS score of 14 and required a therapeutic diet on admission and while a resident. His Baseline Care Plan dated 1/9/26 listed a regular diet with thin liquids, and his Comprehensive Care Plan Report dated 1/21/26 consisted of only one completed care area related to code status, with no care area addressing his need for a therapeutic diet. The facility’s policy stated that comprehensive, person-centered care plans are to be based on resident assessments and developed by an IDT according to the timeframes and criteria in §483.21. For Resident #2, a female with hypertension, renal failure, diabetes mellitus, and irritable bowel syndrome, the Initial MDS assessment showed she was cognitively intact with a BIMS score of 15 and noted a therapeutic diet while a resident. Her Order Summary Report reflected an order for a controlled carbohydrate diet starting 1/30/26, but her Baseline Care Plan for that date listed a regular diet with thin liquids. Her Comprehensive Care Plan Report, dated 1/21/26, similarly contained only one completed care area related to code status and did not include her therapeutic diet needs. In interviews, the MDS Nurse Coordinator acknowledged responsibility for completing comprehensive care plans, stated she was behind on completing care plans for new admissions, and confirmed that the care plans for both residents were incomplete and lacked therapeutic diet information. The report states that this deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.
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