Failure to Implement Comprehensive Care Plan for Resident with Significant Weight Loss
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan consistent with the needs of a resident who experienced significant unplanned weight loss. The resident, who had multiple diagnoses including septic shock, hypertension, chronic kidney disease, and a non-pressure chronic ulcer, was cognitively intact and required extensive assistance with activities of daily living. Despite the resident's report of losing 42 pounds and dissatisfaction with facility food, the care plan did not include measurable goals, and key interventions such as weekly weights and dietary preference reviews were not implemented or documented. Clinical record review showed a weight decrease from 205 pounds to 166.8 pounds over several months, with no evidence that weekly weights were obtained or attempted. The care plan listed interventions like RD consults, meal intake monitoring, and supplements, but there was no documentation that these were carried out. Interviews with facility leadership confirmed that care plans should be individualized and measurable, but in this case, the care plan lacked measurable goals and the interventions were not followed.