Failure to Implement Comprehensive Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames to address the medical, nursing, mental, and psychosocial needs of a resident experiencing weight loss. The resident, who had a history of cerebrovascular disease, hypertension, and type 2 diabetes, was admitted with a stable weight but experienced a gradual decline over several months. Despite the care plan identifying the risk for weight loss due to meal refusal and food preferences, interventions such as providing preferred foods, encouraging meal completion, and monitoring weight were not effectively implemented. The resident's weight decreased from 184.2 lbs to 166.4 lbs over approximately eight months, representing a 9.37% loss. Documentation showed the resident often ate less than 51% of meals, preferred snacks brought by family, and expressed dissatisfaction with facility food. The care plan included goals to maintain ideal weight and interventions like determining food preferences and serving snacks, but these were not consistently followed. The facility's policy required intervention only after a 10% weight loss in six months, and staff did not initiate additional measures such as nutritional supplements or further dietary assessment before reaching this threshold. Interviews with staff revealed that the dietitian only assessed residents with significant weight loss and did not document recommendations for further evaluation. Nursing staff noted the resident's poor meal intake but did not implement new interventions. The resident's family was aware of the ongoing weight loss and dissatisfaction with meals, but no documented changes were made to address these concerns prior to the deficiency being identified.