F0657

E

Failure to Revise Care Plans After Significant Weight Loss, Recurrent Falls, and Change to Comfort Care

Vernon, Vermont Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely develop, review, and revise comprehensive care plans based on residents’ changing conditions, despite an existing policy requiring an interdisciplinary team to do so. For one resident with anemia, GERD, a chronic left foot ulcer, and other malaise, a significant weight loss occurred between two recorded weights, dropping from 123.6 pounds to 114.4 pounds in 15 days, which meets CMS criteria for significant weight loss. Although this resident already had a care plan problem identifying risk for weight changes and an approach to monitor for sudden weight loss, the dietitian’s progress note later documented the weight loss and acknowledged awareness of it, yet the care plan was not updated with any new interventions. The DON stated there should have been a dietitian progress note in December addressing the significant weight loss, and the dietitian admitted awareness of the weight loss and that a note should have been written.

Another resident with unspecified dementia, repeated falls, history of falling, weakness, and unsteadiness on feet had a care plan problem identifying fall risk related to decreased safety awareness. This resident sustained eight documented falls over a three‑month period, including unwitnessed falls in a bathroom and next to the bed, a fall with a “goose egg” or presumed hematoma to the head, a fall forward out of a wheelchair, and multiple other falls in the hallway, outside the room, and while attempting to get out of bed. Despite the repeated falls and detailed nursing progress notes describing each event and associated injuries or lack thereof, there were no new interventions documented in the resident’s care plan after any of these falls. In an interview, the DON confirmed that the care plan should have been updated after each fall but was not.

A third resident identified as at risk for falls due to decreased cognition, poor safety awareness, and needing encouragement to sit or rest had four fall‑prevention interventions in the care plan, all dated the same day. Progress notes later documented that this resident fell while sleeping in a chair, leaning forward and hitting the right frontal head on the floor, resulting in a quarter‑sized bump, and then fell again two days later after a bed alarm sounded, with staff finding the resident on the floor next to the bed and noting a quarter‑sized abrasion to the forehead. Review of the care plan showed no updates or additional interventions added after either fall, and the DON confirmed the care plan was not updated following these events.

A fourth resident with severe cognitive impairment (BIMS score of 99), dependent for ADLs and hygiene, and diagnoses including dementia, history of TIA and cerebral infarction, and major depressive disorder experienced an acute change with facial droop and nonresponsiveness. Nursing progress notes described right‑sided facial droop, nonverbal status, and suspicion of a stroke, with documentation that the POA did not want hospital transfer and requested comfort measures. A physician late entry progress note further documented that staff suspected a cerebrovascular infarction, that the DPOA declined hospital transfer, and that comfort measures were to be initiated and the resident remain at the facility due to advanced dementia and declining quality of life. Despite this clear shift to comfort care, review of the resident’s care plan revealed no information indicating the resident had been placed on comfort care, and the DON confirmed that the care plan was not updated to reflect this change. The facility’s own care planning policy, which requires the interdisciplinary team to develop individualized comprehensive care plans based on the comprehensive assessment, was not followed in these cases.