Failure to Verify Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to ensure a resident's weight was accurately verified following significant changes, resulting in a lack of documentation confirming the accuracy of a substantial weight loss. The resident, who had multiple diagnoses including pleural effusion, heart failure, endocarditis, dementia, and edema, was prescribed furosemide for bilateral lower extremity edema and was identified as clinically at risk due to significant weight fluctuations. Despite care plan interventions that included regular weight monitoring and nutritional support, the resident experienced a marked drop in weight from 188.7 pounds to 145.4 pounds within a short period, with no documentation that the weight loss was verified or rechecked for accuracy. Interviews with facility staff revealed uncertainty regarding the cause of the weight loss, with the DON and RD both acknowledging the need to investigate and verify the resident's weight, including consideration of possible errors such as not subtracting the weight of a wheelchair. The facility's policy required assessment and analysis of risk factors, including the use of diuretics, but there was no evidence that the significant weight change was properly verified or that the physician was notified as required. The deficiency was identified through review of records and staff interviews, which confirmed that the resident should have been reweighed to ensure accuracy.