Failure to Develop and Implement Comprehensive Care Plan for Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's nutritional needs and significant weight loss. Despite the resident being admitted with multiple diagnoses including coronary artery disease, hypertension, diabetes, aphasia, malnutrition, and depression, and having a moderate cognitive impairment, the care plan did not include measurable objectives, timetables, or specific interventions related to the resident's documented weight loss. The resident experienced a notable weight loss from 118.0 pounds at admission to 102.8 pounds within a short period, yet the care plan lacked focus areas, goals, or interventions to address this decline. Additionally, the care plan did not reflect the resident's dietary preferences or supplemental needs associated with a pescatarian diet, even though the dietitian and kitchen staff had worked to accommodate these preferences. There was no documentation of menu choices for pescatarian diets, and the care plan did not address the resident's need for oral nutrition supplements or other individualized interventions. These omissions were confirmed by staff interviews and review of facility policies, which require ongoing assessment and multidisciplinary care planning for weight loss and nutritional risk.