Failure to Complete Ordered Weekly Weights for Resident with Weight Loss
Penalty
Summary
A resident with diagnoses of malnutrition, diabetes mellitus, and congestive heart failure was readmitted to the facility and had a physician's order for weekly weights for four weeks due to an eight-pound weight loss in one month. The resident's care plan and change of condition documentation both reflected the need for weekly weights and ongoing monitoring, as well as the requirement to report significant changes to the physician. Despite these orders and care plan interventions, the last recorded weight for the resident was documented prior to the initiation of the weekly weight order, and no subsequent weekly weights were completed as required. During an interview and record review, a Licensed Vocational Nurse confirmed that the weekly weights were not performed according to the physician's order. The facility's policy on weight assessment and intervention also required monitoring of resident weights for undesirable or unintended weight loss or gain. The failure to obtain and document weekly weights as ordered resulted in inadequate monitoring of the resident's weight loss.