Failure to Update Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident who experienced a significant change in condition related to weight loss. The resident, who had dementia and was at nutritional risk with a mechanically altered diet, lost 6.8% of body weight over a 30-day period. Although a registered dietitian assessed the resident and continued to recommend interventions following the weight loss, the care plan, originally developed months earlier, was not updated to reflect the resident's new nutritional status or to address ongoing weight trends. During the survey, it was found that there was no documented evidence that the care plan had been reviewed or revised after the significant weight loss was identified. No new interventions were added, nor were existing interventions updated to address the change in the resident's condition. The Nursing Home Administrator confirmed that the care plan should have been updated to reflect the resident's current needs following the weight loss.