Failure to Develop Care Plan for Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan for a resident who experienced a significant change in condition, specifically nausea, vomiting, poor meal intake, and notable weight loss. The facility's policy required that all changes in a resident's condition be communicated to the physician, documented in the nursing progress notes and twenty-four hour report, and that the resident's care plan be updated as indicated. Despite these requirements, the medical record review showed that the resident lost 17 pounds over four days and had complaints of nausea, but no care plan was initiated to address these issues. Interviews with facility staff, including an LVN, the DON, and the RD, confirmed that the resident's care plan was not updated to reflect the new problems of poor appetite and weight loss. The RD acknowledged that the resident was at risk for weight loss and verified that no care plan had been initiated to address the resident's poor intake and weight loss. The RD also stated that she did not initiate a care plan problem until the MDS was completed.