F0842

D

Incomplete and Inaccurate Clinical Records for Diet Orders and Catheter Care

Crown Point, Indiana Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves incomplete and inaccurate clinical records related to diet orders and assistive devices for one resident and urinary catheter care documentation for another resident. One resident with Alzheimer's disease and dysphagia had an MDS indicating a mechanically altered diet and a physician's order for a pureed diet with nectar thickened liquids, along with use of a scoop plate and Provale cup. Despite this, the resident was served chicken and rice soup containing chunks of carrots and chicken, which a CNA removed after realizing the resident was on a pureed diet. The resident was repeatedly observed receiving thickened juice in a clear plastic cup rather than the ordered Provale cup. The DON later indicated that a speech therapy discharge summary allowed mechanical soft pleasure feeds and acknowledged that the resident's diet and Provale cup orders needed to be updated, and that the Provale cup could not be used with thickened liquids.

The deficiency also includes inaccurate documentation of urinary catheter care for another resident. This resident, with diagnoses including cholecystitis and a UTI, had severe cognitive impairment and was dependent for toileting, bed mobility, and eating. A physician's order on readmission from the hospital indicated the resident had a urinary catheter with catheter care every shift, and the March Treatment Administration Record showed catheter care documented on multiple days. However, observations showed no urinary catheter present; the DON confirmed there was no catheter and stated it must have been removed while the resident was in the hospital. The Administrator was informed that staff had been documenting catheter care when no catheter was present, and no additional information was provided.