Inaccurate Weight Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate weight measurements for two residents, resulting in incorrect documentation in their medical records. Resident #35 was recorded to have gained 16 pounds in one day, which was later corrected to a 1.7-pound loss after a reweighing prompted by surveyor inquiry. The resident had severe cognitive loss and required assistance with all care. The error was not identified or corrected by the staff until the surveyor's intervention, and the Registered Dietitian (RD) confirmed that weights were not routinely checked for accuracy. Similarly, Resident #47 was documented to have an implausible weight gain of 1,643.5 pounds in one day. This error was also not addressed until the surveyor's involvement. The resident had severe dementia and required assistance with all activities of daily living. The RD stated that she reviewed weights three days a week and would request reweighs if she noticed any abnormal readings. The Director of Nursing acknowledged the issue with weight accuracy in the facility.