Failure to Consistently Obtain and Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to consistently obtain and monitor weights as ordered for two residents reviewed for nutrition. One resident, with multiple diagnoses including diabetes and chronic pain, had weights recorded inconsistently and not according to the physician's order for monthly weights by the 5th of each month. Significant weight fluctuations were noted, including a loss of 6.2 lbs over 11 days and a total loss of 10 lbs over approximately six weeks. The electronic medical record flagged an out-of-range weight, and the registered dietitian recommended weekly weights after a significant loss, but these were not obtained as recommended. The resident expressed distress about the reported low weight, stating she had never weighed below 100 lbs. Another resident, with diagnoses including congestive heart failure, chronic kidney disease, and dementia, had a physician's order for daily weights due to their medical condition and dialysis requirements. However, there were missing weight entries on three separate days, and the nurse's notes did not reflect any weights recorded on those dates. The care plan for this resident included goals to prevent unwarranted weight gain and maintain appropriate weight for dialysis, with the approach to obtain weights as ordered, which was not consistently followed.