Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced significant weight loss. The resident, admitted with diagnoses including dementia, showed an 8.5% weight loss over 90 days as of March 18, 2025. Despite the registered dietitian implementing nutritional interventions, the care plan had not been updated since December 13, 2023, to reflect the resident's current nutritional status and needs. During a survey conducted in April 2025, it was found that the care plan did not include updates or new interventions addressing the resident's weight loss. The Nursing Home Administrator confirmed the oversight, acknowledging that the care plan should have been reviewed and revised in response to the significant change in the resident's condition.
Plan Of Correction
F Tag 0657: 1. Resident 91's plan of care was updated to reflect weight changes with implementation of appropriate interventions. 2. Director of Nursing or Designee will conduct an initial of residents with significant weight changes to verify that their individualized plans of care were completed addressing current weight significant changes and implementation of interventions as warranted. 3. Director of Nursing or Designee will be provided re-education to the Interdisciplinary Care Team on Comprehensive Plans of Care updating/reviewing reflecting weights. 4. Director of Nursing or designee will conduct audits on residents identified as having significant weight changes to verify care plans and implementation of interventions as warranted. The audits will be conducted weekly x 4 weeks and monthly x 3 months. Results of these audits will be brought to the QAPI Committee for review and recommendations.