Failure to Obtain Weekly Weights for New Admission on Tube Feeding
Penalty
Summary
The facility failed to obtain weekly weights as ordered for a newly admitted resident who was receiving enteral tube feedings. The resident was admitted with diagnoses including a Stage IV pressure wound, protein calorie malnutrition, and anemia, and was identified as being at risk for dehydration. Facility policy and physician orders required weekly weights for new admissions, especially those on tube feedings, to monitor nutritional status. However, the resident's medical record showed missing weights on the admission date and on one of the required weekly intervals. Interviews with staff revealed that the Restorative Aide was primarily responsible for obtaining weights, but due to being assigned additional duties such as nurse aide tasks and transporting residents, weights were not always completed as required. The DON confirmed that if the Restorative Aide was unavailable, the assigned nurse was responsible for obtaining the weights, but this did not occur. The Registered Dietitian and the physician both confirmed the importance of weekly weights for this resident, and acknowledged that the required monitoring was not performed as ordered.