Failure to Obtain and Document Weekly Weights
Penalty
Summary
The facility failed to ensure that weekly weights were obtained as ordered by the physician for two residents. Resident R1 was admitted with diagnoses including a fracture of the lower end of the left femur and muscle weakness. A physician's order dated February 12, 2025, required weekly weights for four weeks, then monthly. However, there was no documented evidence that Resident R1 was weighed weekly as ordered, nor was there any indication of refusal to be weighed. An interview with the Unit Manager confirmed the absence of documentation regarding attempts to obtain weights or any refusal by the resident. Similarly, Resident R33, admitted with conditions such as pleural effusion and dysphagia, had a physician's order for weekly weights. After being discharged to the hospital and readmitted, there was no documented evidence of a weight being taken at readmission. The resident's weight records showed gaps greater than seven days between weighings, contrary to the physician's orders. The Unit Manager confirmed the lack of documentation for attempts to weigh the resident or any refusal. These deficiencies indicate a failure to adhere to physician orders and maintain proper documentation.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Resident immediately weighed per physicians' orders. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current will be conducted to ensure physician orders for obtaining weights are followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that physician orders for weights are being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.