Failure to Revise Care Plan After Severe Weight Loss
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident after a significant weight loss event. The resident, who had diagnoses including Type 2 diabetes mellitus with diabetic neuropathy, chronic kidney disease, and cerebral infarction, experienced a severe weight loss of 32.6 pounds (18.09%) in less than one month. Despite facility policy requiring immediate notification and intervention for significant weight changes, there was no documentation of a care plan revision or new interventions to address the weight loss until five months after the event. The care plan was not updated to reflect the resident's weight loss, and there was no evidence that the interdisciplinary team was notified or involved in timely care planning as required by policy. Interviews with staff revealed that the registered dietitian was not informed of the weight change and therefore did not update the nutrition care plan. The DON acknowledged that the weight loss went unnoticed due to a transition period within the facility, resulting in a lack of timely care plan revision. The resident was also not notified of the weight loss. Facility policies outlined the need for prompt action and interdisciplinary involvement in response to significant weight changes, but these procedures were not followed in this case.