Failure to Develop Comprehensive Care Plans for Swelling and Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was readmitted with multiple diagnoses, including cerebral infarction, heart failure, chronic kidney disease, gout, and aphasia. Upon review, it was found that the resident had a severely impaired cognition and was dependent on staff for activities of daily living. Despite documentation of swelling and pain in the resident's left third finger and a significant weight loss of 50 pounds upon readmission, no care plans were created to address these issues. The absence of care plans was confirmed by both the Registered Nurse Supervisor and the Director of Nursing during interviews, with the latter stating that the weight loss was considered under an existing tube feeding care plan rather than a separate plan. Facility policies required that comprehensive, person-centered care plans be developed to address all identified problems and conditions, including undesirable or unintended weight loss. The policies also specified that individualized care plans should include causes, goals, benchmarks, and time frames for monitoring and reassessment. However, the facility did not follow these procedures for the resident's swollen finger or significant weight loss, as evidenced by the lack of corresponding care plans in the resident's records.