Failure to Follow Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to follow a care plan intervention for a resident with documented weight loss and severe cognitive impairment. The resident, who had diagnoses including hypertension, non-Alzheimer's dementia, and cerebrovascular accident, required extensive assistance for most activities of daily living but was independent with eating after staff set-up. The care plan specified that the resident liked to eat in a recliner in the main lobby and required cueing from staff due to frequent meal refusals. However, observations showed that staff did not consistently offer meals or set up food for the resident in her preferred location. On multiple occasions, the resident was not provided a meal tray or redirected to the table when meals were served, despite being present and independently drinking fluids. Staff interviews revealed inconsistent implementation of the care plan interventions. Certified Nursing Assistants and Registered Nurses acknowledged that while they attempted to redirect the resident to the table, they had not set up meal trays at the recliner as directed in the care plan. Staff relied on the kardex or electronic health record for care plan instructions but did not consistently follow the intervention to provide meals in the resident's preferred location. The Director of Nursing confirmed the expectation for staff to follow the care plan and noted that the resident often refused meals, with staff offering snacks throughout the day. The facility's policy required staff to be informed of care plan interventions and updates, but this was not effectively implemented for this resident.