Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan to address a significant weight loss in a resident. The facility's policy requires that residents experiencing unintended weight loss be assessed by the interdisciplinary team, with interventions implemented and documented in the care plan, including measurable objectives and time frames. However, review of the clinical record for a resident who was admitted after a hospital stay, subsequently discharged back to the hospital for gastrointestinal bleeding, and then readmitted, revealed a significant weight loss of 18.8 pounds over eleven days. The resident's weight dropped from 143.8 pounds to 125.0 pounds during this period. Despite this significant weight loss, the registered dietician was only made aware of the issue several days later and, although supplemental shakes were offered and refused by the resident, the care plan was not updated to reflect the new interventions or the resident's current nutritional status. The dietician confirmed that the protocol would involve communication with nursing staff and the physician, followed by an update to the care plan, but this was not completed. The failure to update the care plan and document appropriate interventions constituted noncompliance with facility policy and regulatory requirements.