Failure to Update Care Plan for Weight Loss Interventions
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was revised to reflect current care needs and interventions following a significant weight loss. The resident, who had severe cognitive impairment as indicated by a BIMS score of 5, experienced a seven-pound weight loss within one month. Medical record review showed that the physician ordered weekly weights for four weeks and the administration of an appetite stimulant (megestrol acetate) to address the weight loss. However, these new interventions were not incorporated into the resident's care plan. Interviews with facility staff, including an LVN and the ADON, confirmed that the care plan did not include the updated interventions as ordered by the physician. The facility's policy required the interdisciplinary team to review and revise care plans at least quarterly or after a significant change in condition, but this was not done in this case. The omission posed a risk of not providing individualized and person-centered care for the resident.