Failure to Implement and Specify Nutritional and Weight Monitoring in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to implement and specify care plan interventions related to nutritional monitoring and weight management for two residents with unplanned weight loss. For one resident with diagnoses including DM, dysphagia, and pneumonitis, and with moderately impaired cognition and dependence on staff for most ADLs, the care plan initiated on 12/31/25 identified unplanned/unexpected weight loss related to poor oral intake and food refusal, with a goal of no further weight loss for three months. The care plan interventions required monitoring and recording food intake at each meal and weighing the resident at the same time using a specified scale, but the frequency, time of day, and scale type were not actually documented. Review of the meal intake records showed that this resident’s intake was only recorded on scattered dates and times rather than after each scheduled meal, and the DON acknowledged that monitoring of this resident’s meal intake was inconsistent despite established mealtimes. For the second resident, admitted with DM, protein-calorie malnutrition, reduced mobility, moderately impaired cognition, and dependence or substantial assistance for most ADLs, the care plan initiated on 12/10/25 documented an unplanned/unexpected seven-pound weight loss in one week related to disease process, with a goal of no further weight loss for three months. The nursing interventions included weighing the resident at the same time of day and recording the weight, but again the care plan did not specify the frequency of weighing, the time of day, or the scale to be used. During concurrent interview and record review, the DON confirmed that the care plans for both residents lacked these specific details and stated that the care plan should be specific and thorough. Facility policies on comprehensive care plans and weight management required development and implementation of person-centered care plans and review and updating of care plans as indicated, but the documented care plans for these two residents did not include the required specificity for weight monitoring.
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