HospitalInspections.org

Based on interview, record review and review of facility policies and procedures the facility failed to have an updated patient (Patient #1) care plan for a patient that was recently changed to a "Dysphagia (difficulty swallowing) diet.

Failure to maintain an updated plan of care for patients potentially puts them at risk for harm when staff do not have current knowledge of the patient's care needs and/or precautions to take when caring for the patient.

Findings include:

1. The policy entitled "Treatment Planning", Policy 8.01 read in part under "M. Treatment plans must be re-evaluated continually. When a significant change occurs, the treatment team will hold an ad hoc ETC (Evaluation and Treatment Conference) to review patient progress towards goals and revise the plan accordingly".

2. Review of Patient #1's record revealed the patient was ordered a "Dysphagia diet" on 12/28/2016 by their physician. With the patient to be in line of sight for all meals due to aspiration risk. There was no documentaion that the patient's treatment plan/care plan was updated to reflect this change.

On 2/28/2017 the physician wrote to continue the patient on "Dysphagia diet with pureed nectar and thick liquids". The physican ordered 1:1 monitoring during all meals. There was no docmentation on the patient's treatment/care plan to reflect this change.


3. The above information was verified with a licensed nurse, Contact #1 on 3/29/2017 at 10:00 AM. The nurse stated the care plan/treatment plan needed to be updated by the licensed nurse anytime a patient's medical condition changed and precautions to be used should be put in the patient's treatment/care plan as indicated.