F0657

D

Failure to Revise Nutritional Care Plan After Swallowing Assessment

Silver Spring, Maryland Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to revise a resident’s care plan to reflect updated swallowing assessment results and related nursing interventions. A resident was admitted with diagnoses including severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate, and had a BIMS score of 3/15, indicating severe cognitive impairment. The dietician developed a nutritional risk care plan dated 12/29/25, with goals for the resident to tolerate a modified diet texture/consistency and maintain adequate nutritional status, and interventions such as administering medications as ordered, monitoring and reporting signs and symptoms of dysphagia, providing 1:1 assistance with meals as needed, providing supplements, serving the ordered diet and monitoring intake, and having the dietician evaluate and recommend diet changes as needed.

During the admission process, the facility SLP evaluated the resident on 12/30/25 and, after discussion with the responsible party, obtained physician orders and scheduled a FEES exam, which was completed on 01/09/26. The FEES results recommended a soft and bite-sized/mechanical soft chopped diet with thin liquids and compensatory strategies including sitting upright, no straws, single sips, small bites, and a slow rate of intake, with consideration of a Provale cup if single sips were not completed independently. These FEES results were available to staff the same day. However, interview with an RN on 03/05/26 confirmed that the resident’s Nutritional Risk care plan was not updated with any new nursing interventions following the 01/09/26 FEES procedure, leading to the determination that the facility failed to revise the care plan to meet the resident’s needs.