Failure to Update Care Plan and Document Rationale for Diet Change
Penalty
Summary
Surveyors identified that the facility failed to update an individualized care plan to reflect a resident’s current diet order and failed to address discontinued resident-specific nutritional interventions. Facility policies required that diet orders be provided as ordered by the healthcare provider, that the tray card system match the medical record, and that comprehensive care plans be updated on an ongoing basis to reflect resident needs, wishes, or changes in condition. The resident involved had diagnoses including diabetes mellitus, hypertension, and dementia. A Medical Nutritional Therapy assessment documented a diet order of mechanical soft with low concentrated sweets (LCS). A clinical progress note later recommended advancement to regular solids and thin liquids, and the physician order for LCS, mechanical soft was discontinued and replaced with a regular diet order. The facility’s EMR diet order report and the dietary tray card system both showed a regular diet for the resident. Despite these changes, the resident’s nutrition status care plan, last updated several days before the diet change, continued to list an intervention to provide an LCS, mechanical soft texture diet and was not revised to reflect the current regular diet order. The RN Assessment Coordinator confirmed that the care plan did not match the current diet order. A subsequent RD progress note also indicated the resident was on a regular diet, but the clinical record did not contain documentation from the RD or physician providing a rationale for discontinuing the LCS therapeutic diet restriction. The Regional Risk staff member confirmed the absence of this rationale in the record, and the Administrator and DON acknowledged that the facility failed to update the individualized care plan to address the resident’s specific nutritional concerns and preferences and failed to address the discontinued resident-specific interventions.
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