Failure to Update Care Plan After Diet Texture Change Following Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s comprehensive care plan after a physician-ordered change in diet texture following an aspiration event. The resident had multiple diagnoses, including cerebral palsy, schizoaffective disorder, dysphagia, metabolic encephalopathy, seizures, protein-calorie malnutrition, hypothyroidism, schizophrenia, anxiety, and psychosis. The admission record and H&P documented that the resident was not self-responsible, could not make medical decisions, and had a conservator. The MDS showed severe cognitive impairment, short- and long-term memory problems, and a need for moderate assistance with eating, with documented issues of losing liquids/solids from the mouth and coughing or choking during meals or when swallowing medications. On a specified date, a Change of Condition (COC) documented that the resident experienced an episode of aspiration while eating, with coughing, difficulty clearing the throat after swallowing, and shortness of breath, and that this condition had not occurred previously. The COC indicated the primary physician recommended downgrading the resident’s diet. Physician orders dated the same day changed the diet to minced and moist/IDDSI Level 5 texture. The following day, an SLP evaluation and plan of treatment documented anterior-to-posterior transit delay, decreased bolus formation, and a tendency for the resident to overstuff her mouth, and recommended a minced and moist texture as tolerated, with any advanced diet texture trials to be provided only through the SLP. Despite these changes, the resident’s existing care plan, originally dated several months earlier, still directed CNAs, LPNs, and RNs to provide and serve a regular, easy-to-chew/IDDSI Level 7 diet. During interviews and concurrent record reviews, an LVN confirmed that the resident’s coughing and shortness of breath indicated a potential aspiration event and that the physician had ordered a diet change to prevent further choking and aspiration, stating that the care plan should have been updated to reflect the new orders. The SLP also stated that the resident’s care plan interventions were not updated to reflect the new physician-ordered diet texture. The facility’s policy on Comprehensive Plan of Care required that the comprehensive care plan address individual needs, include interventions to manage risk factors, and be reviewed and revised by the interdisciplinary team as changes in the resident’s care and treatment occur, including in response to changes in physical or functional status.
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