Failure to Assess and Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to accurately assess the nutritional status of a resident and did not update the individualized care plan to address specific nutritional concerns. The facility's policy requires a comprehensive nutritional assessment, including current status and risk factors, to be conducted upon admission and as indicated by changes in condition. For one resident with diagnoses of traumatic brain injury, aphasia, and heart disease, the Minimum Data Set (MDS) indicated significant weight loss. However, the clinical dietary assessment note did not identify the parameters of this weight loss, such as prior weights or specific time frames. Additionally, the resident's nutritional plan of care was not updated to reflect a focus on the significant weight loss, nor did it include goals or interventions to address the issue. Staff interviews confirmed that the assessment and care plan failed to address the resident's nutritional concerns as identified in the MDS. This deficiency was found during a review of four resident records.