Failure to Revise Care Plan for Nutritional Changes
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 84, to reflect changes in nutrition despite a significant weight loss. Between December 14, 2024, and January 6, 2025, Resident 84 experienced a 5.89% weight loss. A weight warning note from the dietitian, dated January 6, 2025, identified this weight loss and suggested adding pudding to lunch and dinner, as well as adding dessert for additional calories. However, a review of Resident 84's care plan revealed that it was not updated to include these nutritional changes recommended by the dietitian. An interview with the Director of Nursing on January 31, 2025, confirmed that the care plan had not been revised to incorporate the dietitian's recommendations. This oversight was noted as a deficiency in the facility's compliance with care plan revision requirements.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. Facility failed to revise a care plan to reflect changes in a R84s weight loss. Care plan updated for this resident. 2. Audit of current residents with weight loss completed to ensure that residents have care plans in place and are updated. 3. DON/ Designee will complete training for licensed staff on the components of this regulation to include the need to update care plans. 4. DON/Designee will complete audits of 5 residents with weight loss weekly 2 x a week x 4 weeks, then 1 x a week x 4 weeks, then 2 x a month, then 1 x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings in QAPI. 5. Date of compliance will be 2/28/25.