Failure to Implement Care Plan Interventions for Significant Weight Loss
Penalty
Summary
The facility failed to implement care plan interventions for a resident with complex medical needs, including Amyotrophic Lateral Sclerosis, quadriplegia, and ileus. According to the facility's policy, all disciplines providing care are required to review and contribute to the resident's care plan, which should address services necessary to maintain the resident's highest practicable well-being. The resident's care plan for enteral feeding included monitoring for weight changes greater than 5% in one month and consulting a dietitian for caloric intake needs as needed. A review of the resident's records showed a significant weight loss from 69 kilograms to 59.9 kilograms over a period of less than two months. The resident refused to be weighed in one month, but the subsequent weight indicated a 14% loss. Despite this, no action was taken regarding the resident's weight loss, and the registered dietitian was not aware of the change until it was brought to their attention during the survey. This demonstrates that the care plan interventions, specifically monitoring and responding to significant weight changes, were not implemented as required.