Failure to Update Care Plan for 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 Resident #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 was not eating much, and family members confirmed the resident's decreased appetite. The facility's staff, including a Certified Nursing Assistant (CNA) and the Diet Technician (DT), were unaware of the resident's significant weight loss. The DT stated that she was responsible for nutritional assessments upon admission but did not know about the resident's weight loss. The Registered Dietician (RD) confirmed that she had documented the weight loss but had not seen the resident in person. The RD acknowledged that the care plan should have been updated with new interventions and that the interdisciplinary team had not met to address the resident's weight loss. Interviews with the Occupational Therapist (OT) revealed that the focus was on the resident's ability to eat independently rather than meal consumption. The OT stated that the dietician would typically communicate with the Director of Rehab (DOR) if there were concerns about weight loss. The facility's policy on comprehensive care plans emphasized the need for timely updates and revisions by an interdisciplinary team, but this was not followed in the case of Resident #162.
Plan Of Correction
Resident # 162 was discharged from the facility. 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 residents with a significant 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.