Failure to Re-Weigh and Notify on Significant Resident Weight Changes
Penalty
Summary
Staff failed to obtain a follow-up weight for a resident who experienced significant fluctuations in weight, including a 23.65% loss in one month followed by a 27.49% gain the next month. There was no documentation of any re-weighing to confirm these significant changes, nor was there evidence that the physician, dietitian, or family representative were notified of the weight variances. The facility's own policy required re-weighing for weights outside the normal range and notification of significant weight changes, but these steps were not documented as completed. Interviews with staff revealed inconsistent practices regarding resident refusals to be weighed, with some staff stating they would attempt multiple times and inform management if a resident refused. However, there was no documentation of refusals or follow-up attempts for this resident, and some staff indicated the resident did not typically refuse to be weighed. The facility lacked a clear documentation policy for these situations, despite having written guidelines for weight tracking and management.