Failure to Develop Comprehensive Care Plan for Weight Changes
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R33, who experienced significant weight changes. The facility's policy requires that a comprehensive person-centered care plan be developed and implemented for each resident, including measurable objectives and timeframes to meet their physical, psychological, and functional needs. However, upon review of Resident R33's clinical record, it was found that there was no documented evidence of a care plan addressing the resident's weight loss. Resident R33 was admitted to the facility with diagnoses including pleural effusion, dysphagia, and cognitive communication deficit. The resident's weight records showed a significant decrease from 180 lbs at admission to 150.4 lbs over a period of approximately two months, indicating a weight loss of 16.4%. Despite this notable weight change, the facility did not develop a care plan to address the resident's nutritional needs, which is a requirement under the facility's policy and federal regulations.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The care plan for Resident R33 was updated to include goals and interventions for the residents specific goals and needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents will be conducted to ensure that a comprehensive care plan was developed and implemented and that a written summary of the comprehensive care plan was provided to the resident and/or resident representative. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that a comprehensive care plan was developed and that the resident/ resident representative received a copy of the baseline care plan. Audits will be conducted weekly for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.