Failure to Develop and Implement Care Plan for Refusal of Weight Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's ongoing refusal to allow body weight monitoring. Despite physician orders for weekly weights and documentation in the nutrition/dietary progress notes that the resident was refusing to be weighed, there was no evidence in the resident's care plan or progress notes that this refusal was addressed. The resident had multiple diagnoses, including hypothyroidism, diabetes mellitus, hypertension, and morbid obesity, and required varying levels of staff assistance for daily activities, but was cognitively intact. Interviews with nursing staff revealed that the refusal to be weighed was not communicated among the care team, and the physician was not notified of the resident's ongoing refusals. Facility policy required that a care plan be developed and revised as resident conditions changed, but no such care plan or interventions were documented for the resident's refusal to allow body weight monitoring. The lack of documentation and care planning had the potential to negatively affect the delivery of care and services for the resident.