Failure to Update Care Plans with Weight Loss Interventions
Penalty
Summary
The facility failed to update the care plans with new weight loss interventions for two residents who experienced significant unplanned weight loss. For one resident with diagnoses including cerebral palsy, epilepsy, intellectual disabilities, hypothyroidism, bradycardia, dysphagia, and gastrostomy status, a significant weight loss of 13.2% in one month was documented. Although physician orders were in place for nutritional supplements, these interventions were not reflected in the resident's care plan after the weight loss was identified. Similarly, another resident with quadriplegia, cerebral infarction, Alzheimer's, type 2 diabetes, and major depressive disorder experienced a 16.6% weight loss over six months and 5.2% in one month. This resident also had physician orders for nutritional supplements and double meal portions, but the care plan was not updated to include these interventions after the significant weight loss was identified. The facility's policy requires individualized care plans to address causes of weight loss, set goals, and include interventions and monitoring parameters. However, the dietary manager confirmed that the care plans for both residents were not updated with the new physician-ordered interventions following the identification of significant weight loss. This omission was acknowledged during interviews, with the dietary manager stating that the updates had not yet been made.