Failure to Implement Resident-Centered Care Plan for Weight Management
Penalty
Summary
The facility failed to implement a resident-centered care plan for one resident with multiple complex medical conditions, including chronic obstructive pulmonary disease, systemic lupus erythematosus, legal blindness, schizophrenia, epilepsy, and a contracture of the left hand. The resident was noted to have moderately impaired cognitive functioning and was independent with eating but required supervision for oral hygiene. The care plan documented that the resident was non-compliant with weight management and included an intervention to notify the physician of this non-compliance. However, there was no documented evidence that the physician was notified when the resident refused monthly weight measurements over a four-month period. The resident reported significant weight loss since admission and confirmed refusal of monthly weight checks. The facility's records showed that weights were not recorded for four consecutive months, with only an asterisk indicating refusal. During interviews, the Dietary Supervisor and DON confirmed the lack of documentation regarding physician notification and acknowledged that the care plan was not implemented as written. The facility also did not have a policy addressing the implementation of resident care plans.