Failure to Develop and Implement Comprehensive Care Plan for Hearing and Nutrition
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the hearing and nutritional needs of a resident with a history of psychomotor and cognitive communication deficits. Despite multiple clinical records and progress notes documenting that the resident was hard of hearing and the resident's own report of difficulty hearing and lack of hearing aids, there were no care plan goals or interventions in place to maintain or support the resident's hearing. Staff interviews confirmed the absence of hearing aids and the lack of related care planning, even though the facility's policy requires care plans to reflect recognized standards of practice for identified problem areas. Additionally, the facility did not address significant weight loss in the same resident, who experienced an 8.63% decrease in body weight over a three-month period. Although the resident was identified as being at nutritional risk and received a mechanically altered diet, the care plan did not include interventions or communication regarding the resident's ongoing weight loss. Dietary notes and staff interviews confirmed that the resident's weight had been trending downward and that supplemental nutrition was recommended, but there was no evidence of interdisciplinary team meetings or updated care planning to address the weight loss, contrary to facility policy.