Failure to Address Weight Loss in Resident Care Plans
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement comprehensive care plans addressing significant weight loss for two residents. For one resident with severe cognitive impairment and multiple diagnoses, including dementia and anemia, the medical record and MDS documented a weight loss of over 5% in the last month. Despite this, the resident's care plan, last revised after the weight loss was identified, did not include interventions or goals related to the weight loss. Staff interviews confirmed that the weight loss was recognized and coded in the MDS, but the care plan was not updated as required by facility policy. Similarly, another resident with multiple diagnoses, including cancer and chronic kidney disease, and who was cognitively intact, experienced a weight loss of over 5% in the last month as documented in the MDS. This resident also frequently refused meals and medications, as noted in progress notes. However, the care plan did not address the resident's refusal to eat or the risk for weight loss. Staff confirmed that the issue was identified in the MDS but not incorporated into the care plan, indicating a failure to ensure that all identified needs were addressed in accordance with facility policy.