Failure to Update Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to revise the care plan for a resident with severely impaired cognition who experienced significant weight loss. Despite documented orders for a fortified diet and nutritional supplements, the resident's care plan did not reflect these interventions. The resident's medical record showed ongoing weight loss, with the registered dietician recommending a fortified diet and physician notification due to inadequate oral intake. However, the care plan was not updated to include the fortified diet or health shakes, and staff were not consistently providing the required built-up utensils during meals as directed in the care plan. Observations revealed that staff did not offer the resident drinks during meals and failed to provide built-up utensils, which were necessary for the resident's ability to eat independently. Interviews with staff confirmed that the care plan had not been updated to include the fortified diet and that there was uncertainty about the use of built-up utensils. The facility's policy required the care plan to be an active, person-centered document reflecting current care needs, but this was not followed, resulting in uncommunicated care needs and placing the resident at risk for continued weight loss.