Failure to Implement Comprehensive Care Plans for Weekly Weights
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included measurable objectives and timeframes to meet the medical, nursing, mental, and psychosocial needs of two residents. Specifically, the care plans for both residents did not ensure that weekly weights, as ordered by their physicians, were consistently obtained and documented. For one resident with morbid obesity and chronic systolic heart failure, the care plan included a goal to maintain stable weight and interventions to provide a specific diet, but there was no evidence of weekly weights being recorded between two documented dates over a month apart. For another resident with mild protein-calorie malnutrition and dementia, the care plan addressed unplanned weight loss and included interventions such as weekly weights and monitoring for further weight loss. However, weight records showed that weekly weights were not consistently documented, with a gap of over a month between recorded weights. Both residents had active physician orders for weekly weights, but the facility did not ensure these orders were followed. Interviews with staff revealed inconsistencies in the process for weighing residents, with some CNAs stating they always weighed residents as required, while others described weighing residents monthly or passing information between shifts if weights were missed. Nursing leadership acknowledged that residents were not being weighed as ordered and described the process for assigning and recording weights, but the documentation did not support that weekly weights were consistently obtained as required by the care plans and physician orders.