Failure to Notify Provider of Significant Weight Gain per Care Plan
Penalty
Summary
The facility failed to follow care planned interventions for a resident with multiple complex medical conditions, including heart failure, chronic kidney disease, diabetes, and malnutrition, who was dependent on staff for most activities of daily living. The resident's care plan required daily weights and mandated staff to notify the provider if the resident gained more than three pounds in a day or five pounds in a week. Despite documented weight gains exceeding these parameters over several days, there was no evidence in the medical record that the provider was notified as required by the care plan. Interviews with staff confirmed awareness of the care plan's requirements and the resident's fluctuating lower leg swelling, but also revealed that no progress notes or provider notifications were documented regarding the significant weight gain. The interdisciplinary team, including nursing and dietary staff, discussed weight concerns in meetings, but the lack of timely provider notification and documentation represented a failure to implement the care plan as written.