Failure to Address Significant Weight Fluctuations in Resident
Penalty
Summary
The facility failed to address significant weight fluctuations in a resident, identified as Resident #701, who was being monitored for weight loss. The resident had a history of lymphedema, cellulitis, congestive heart failure, anxiety, and an ulcer on the left lower leg. Despite being weighed almost daily, the resident's weight varied dramatically, with differences ranging from 10 to 82 pounds over short periods. These fluctuations were not meaningfully investigated or addressed by the facility, and there was no substantial intervention to determine the accuracy of the weights recorded. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA), revealed that the weight discrepancies were noted but not adequately addressed. The ADON and CNA reweighed the resident after noticing an 82-pound drop in three days, confirming the weight but failing to investigate further. The Registered Dietitian (RD) acknowledged the weight fluctuations but attributed them to the resident's disease process and did not take further action to address the inconsistencies. The RD's progress notes were contradictory, as they mentioned both intended weight loss and a lack of discussion with the resident about such plans. The facility's policy on weights required reweighs when a resident's weight changed by more than five pounds, but this was not consistently followed. The RD's documentation did not provide a clear explanation for the extreme weight variations, and there was no documentation around the time of the most significant weight drop. The facility did not provide additional documentation to explain the weight variations, indicating a lack of compliance with their weight management program.
Plan Of Correction
F692 Nutrition/Hydration Status Maintenance Element 1 Resident #701 currently does not reside within the facility. Element 2 Like residents were identified as residents that reside within the facility. Like residents was audited to ensure they have accurate weight. A facility weight schedule was audited to ensure residents have been weighed and documented accurately. Element 3 The procedure to implement the plan of correction included: 1. IDT reviewed F692. 2. The weight schedule was reviewed and deemed appropriate. 3. The policy Weight was reviewed and deemed appropriate. 4. CNAs and Nurses were re-educated on the documentation of weight with emphasis on ensuring weights are documented accurately. 5. Dietician was re-educated on addressing fluctuations on residents weights. Element 4 The process to ensure that the specific citation remains corrected includes: 1. The Director of Nursing / Designee will audit 10 residents weekly scheduled for weights to ensure they have been provided and documented accurately. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. 2. The Administrator will be responsible for sustained compliance.