Failure to Revise Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced a significant unintentional weight loss of 5% in one month. The resident, who was admitted with multiple diagnoses including depression, adult failure to thrive, diabetes, and COPD, expressed a desire to regain weight. Despite the facility's policy requiring re-weighing and dietitian consultation for significant weight changes, the resident's care plan was not updated to address the weight loss. Interviews and record reviews revealed that the resident consumed 25% or less of meals 63 times out of 86 meals monitored over a month. The Registered Dietitian acknowledged the significant weight loss but had not discussed it with the resident or revised the care plan. The Resident Care Manager noted that the resident refused to be re-weighed, and the facility's protocol did not account for such refusals. The facility Administrator confirmed that the care plan should have been updated to reflect the resident's weight loss.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident 4's care plan was corrected to reflect the significant weight loss of 5% in one month. How the facility will identify other residents having the same potential to be affected by the same deficient practice and what corrective action will be taken? All other residents with significant weight loss have the potential to be affected. RD will conduct 100% audit of all residents with significant weight loss to ensure interventions and/or revisions are reflected in the care plan. What measures will be put into place or what systematic changes will you make to ensure that the deficient practice does not recur? Resident Care Managers, RD, and LN were inserviced by DNS to ensure care plan is to be updated with significant weight loss. How the facility plans to monitor its performance to make sure that the solutions are sustained. RCMs will check each care plan to ensure significant weight loss is present if indicated weekly x4 weeks, then monthly x90 days. Results will be reviewed by QA Committee. Date corrective action will be completed: 4/3/2025