Failure to Monitor Resident Weights
Penalty
Summary
The facility failed to ensure that weekly weights were obtained for two residents with a history of weight loss. Resident R39, who has Huntington's Disease, dysarthria, and dysphagia, had a physician's order for monthly weights, but there were significant gaps and inconsistencies in the weight records. Notably, there were no weights recorded for July 2024, and the resident refused to be weighed in August 2024 without any documented re-weigh attempts. Additionally, a disputed weight in December 2024 was not rechecked, as confirmed by the Regional Nurse. Resident R74, with a history of alcohol abuse and dementia, also experienced lapses in weight monitoring. The resident's care plan indicated a potential nutritional risk, yet weights for May and July 2024 were missing. This lack of documentation hindered the ability to assess weight changes, as noted in a nutrition assessment from August 2024. Resident R240 experienced a significant weight loss of 57.8 pounds over six months, with multiple hospitalizations during this period. Despite physician orders for daily weights, there was no documentation of these weights being obtained. The resident's nutritional assessments indicated regular diet intake, but the weight loss was attributed to hospitalizations. The Registered Dietitian noted the significant weight loss and recommended interventions, but the cause of continued weight loss post-hospitalization remained unclear.
Plan Of Correction
1. Resident R39 and R74 had not suffered any adverse effects. Resident 240 signed onto hospice services with admitting diagnosis of Failure to Thrive. 2. The Director of Nursing or designee will conduct an initial audit of current residents with a physician order for weekly weights obtained as ordered and comply with the Genesis Weight policy for the last 7 days. 3. NPE/IP or designee will educate current licensed nurses to ensure residents with weekly weights are obtained per physician orders and comply with the Genesis Weight policy. 4. The DON or designee will conduct weekly random audits of 5 residents per week x 12 weeks of residents with orders for weekly weights, to ensure compliance with the Genesis Weight policy. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.