Failure to Update Care Plans After Significant Changes in Resident Condition
Penalty
Summary
The facility failed to update care plans in a timely manner for three residents following significant changes in their conditions. One resident experienced a significant weight loss of over 10% in six months, as documented in the weight summary, but the care plan was not updated to reflect this change. Another resident, who was at nutritional risk due to multiple medical conditions and had severely impaired cognition, also experienced a weight loss of nearly 15% over five months, yet the care plan did not reflect this significant change. Staff interviews confirmed that the care plans for both residents should have been updated to address the significant weight loss, but this was not done, partly due to a recent change in dietician staffing and unclear responsibilities for updating care plans. Additionally, a third resident's care plan continued to indicate the need for dialysis, despite the resident no longer receiving dialysis services. The resident and staff interviews confirmed that the resident had not been on dialysis for some time, and the care plan had not been revised to reflect this change. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition, but this was not followed in these cases.