Failure to Address Weight Discrepancies and Obtain Required Weights
Penalty
Summary
The facility failed to properly address significant weight discrepancies and to obtain required daily weights for multiple residents, as evidenced by record review and staff interviews. For one resident with chronic heart failure and severe cognitive impairment, there were notable fluctuations in recorded weights, with no documentation that these discrepancies were addressed or that weights were consistently obtained before breakfast as ordered by the physician. The care plan required daily weights and prompt reporting of significant changes, but the records did not show compliance with these interventions. Staff interviews revealed concerns about the accuracy of the scale and a lack of timely recalibration, despite awareness of the issue. Another resident with a history of protein calorie malnutrition, dysphagia, and a gastrostomy tube experienced a documented significant weight loss over several months. The registered dietitian questioned the accuracy of the weights and recommended a re-weigh, but there was no evidence that this was promptly carried out. The resident's care plan included weekly weights, but inconsistencies in the scale and lack of timely follow-up on questionable weights were noted. The DON acknowledged the expectation that re-weights should be done promptly when significant discrepancies are identified, but this was not documented in the records. A third resident with chronic systolic congestive heart failure had a physician's order for daily weights before breakfast, with instructions to report significant weight gains. However, documentation was missing for several days, and there was no record of refusals or reasons for not obtaining the weights. The DON confirmed that daily weights were required due to the resident's diagnosis but could not find evidence that the weights were consistently obtained or that omissions were explained. Facility policy required prompt notification and re-weighing for significant discrepancies, but this was not consistently followed.