Failure to Update Care Plan Following Significant Weight Loss and Diet Change
Penalty
Summary
The facility failed to update the care plan for a resident with significant weight loss, despite changes in the resident's condition and new physician orders. The resident, who had diagnoses of type 2 diabetes and hypertension, experienced a 16-pound (13.3%) weight loss over three months. Nursing staff noted the weight loss and recommended weekly weights and a fortified diet to encourage weight gain. A physician order was placed for a fortified regular diet with specific restrictions and consistent carbohydrate intake. However, the resident's care plan for nutrition was not updated to reflect these new interventions and dietary orders. The Director of Nursing confirmed during interviews and record reviews that the care plan was not revised as required by facility policy, which mandates care plan updates when there is a significant change in a resident's condition. The delay in updating the care plan was attributed to an oversight by the nurse who received the order.