Failure to Obtain Resident Weight as Ordered
Penalty
Summary
The facility failed to obtain a resident's weight as ordered by the physician. The resident, who had multiple diagnoses including cerebral palsy, altered mental status, urinary tract infection, heart failure, quadriplegia, and anxiety disorder, was dependent on staff for all activities of daily living. The physician's order required the resident to be weighed every Sunday for four weeks and then monthly, but there was also a conflicting order to weigh every Wednesday. The weight records showed that weights were documented on several dates, but no weight was recorded for the required date of 1/2/2021. During a review with the DON, it was acknowledged that there was a typographical error in the order summary, and the resident should have only been weighed on Sundays. The DON confirmed that the resident was not weighed as ordered on the specified date. The facility's policy required weights to be obtained upon admission and at intervals established by the interdisciplinary team, but this was not followed in this instance.
Plan Of Correction
F 692 NUTRITION/HYDRATION STATUS MAINTENANCE CFR(s): 483.25(g)(1)-(3) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/21. The Director of Nursing Services (DON) conducted an in-service training with the Restorative Nurse Assistants (RNA) on 5/20/25, to conduct scheduled weekly weights for four weeks from the date of admission. Weekly weights will be taken on a specific day of the week, if indicated on the physician's order. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All newly admitted residents had the potential to be affected by this deficient practice. The Medical Records Director (MRD) reviewed the weekly weights in the last two weeks to ensure weekly weights were taken and documented. No other residents were identified. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The DON conducted in-service education with the RNAs on 5/23/25, regarding facility policy on "Weight Assessment and Intervention," focusing on taking weights upon admission and weekly thereafter for four weeks. The MRD will audit the weight record of newly admitted residents weekly for four weeks from admission to ensure that weights are recorded as ordered. The DON and/or her designee will conduct weekly random record reviews of five (5) newly admitted residents for 30 days to ensure that the timely and accurate documentation of the weekly weight is done. Any licensed nurse or RN staff identified with deficient practice will be given one-on-one education. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON and MRD will report findings to the Quality Assessment and Assurance Committee (QAA) for the next three months regarding results of the random checks. The Administrator will monitor compliance through review of DON & MRD reports. CORRECTIVE ACTION COMPLETION: May 23, 2025 PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The DON conducted an in-service education with licensed nurses on 5/23/25, regarding facility policy on "Request for Diagnostic Services," to ensure diagnostic services will be promptly carried out as instructed by the physician's order. The MRD will conduct daily audits of the diagnostic orders for the next three months to ensure that it was done and results were on file. A report of the audit will be submitted to the DON for follow-up. The RN Supervisor during the 7-3 shift will review the diagnostic orders daily from the previous day and follow-up with diagnostic personnel on the results to avoid delay in notifying the physician. The DON and/or her designee will conduct weekly random reviews of 10 residents with orders for diagnostic tests to ensure compliance with policy for the next three months. Licensed staff identified with deficient practice will be given one-on-one in-service education. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON and MRD will report findings to the Quality Assessment and Assurance Committee (QAA) for the next three months regarding weekly random checks. The Administrator will monitor compliance through review of SSD logs. CORRECTIVE ACTION COMPLETION: May 23, 2025 This page intentionally left blank. This page intentionally left blank.