Failure to Update Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident. The resident, identified as #162, experienced a 10.53% weight loss, which was not addressed in the care plan. The care plan, last updated prior to the weight loss, included interventions such as dietician evaluations and medication administration but did not reflect the recent significant weight change. Observations and interviews revealed that the resident had a history of variable intake and meal refusals, which were not adequately addressed. The resident's family noted a significant decrease in the resident's eating habits. Staff interviews indicated that the resident consistently ate less than 25% of meals, yet this was not communicated effectively to the nursing staff or reflected in the care plan. The facility's Registered Dietician confirmed that the resident's significant weight loss was documented but not followed up with appropriate care plan updates or interdisciplinary team meetings. The dietician had recommended supplements, but there was no evidence of a revised care plan or additional interventions to address the resident's nutritional decline. The lack of communication and coordination among staff contributed to the failure to update the resident's care plan appropriately.
Plan Of Correction
The facility residents with significant loss have the potential to be affected by not revising the care plan with changes and new interventions. Residents with a significant loss will be reviewed by the Registered Dietitian/Designee to determine if a significant change assessment and or care plan revision is needed. Revisions and updates will be completed as indicated. The Director of Nursing / Designee will educate the Registered Dietitian, Dietary Tech, Minimum Data Set Coordinators on the need to complete an assessment, and revise the care plan with new interventions for residents with a significant change in status in loss so that the care plan accurately reflects the resident. The Director of Nursing/Designee will complete 3 random weekly audits on loss to determine if the care plan accurately reflects the residents significant loss and/or if revisions are needed. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.