Failure to Develop Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced significant weight loss shortly after admission. The resident, who had diagnoses including unspecified-calorie malnutrition, dysphagia, and pneumonitis due to inhalation of food and vomit, lost 7.2 pounds (5.9 percent of body weight) within 14 days. The Minimum Data Set indicated the resident had moderately impaired cognition, and the nutrition assessment by the Registered Dietitian confirmed the recent weight loss. Despite these findings, there was no evidence that a care plan addressing the resident's nutritional needs and weight loss was developed. Facility policy required that any weight change of 5 percent or more since the last assessment should prompt immediate written notification to the dietitian and physician, and involve a multidisciplinary team including nursing staff, the dietitian, the consultant pharmacist, and the resident or their legal surrogate. However, the records and interviews indicated that this process was not followed for the resident in question, resulting in a lack of timely and coordinated care planning to address the resident's nutritional status.