Failure to Ensure Accurate Weight Monitoring for Two Residents
Penalty
Summary
The facility failed to ensure accurate weights were obtained for two residents, resulting in inconsistent and unreliable weight records. For one resident with diagnoses including adult failure to thrive, major depressive disorder, and type 2 diabetes, the medical record showed significant fluctuations in recorded weights over several months, with no documentation of weight refusals. The care plan identified the resident as severely underweight and required regular weight monitoring and reporting of significant changes. However, progress notes indicated that reweights requested by the dietician were not always obtained, and staff did not consistently use the same scale or subtract wheelchair weight as needed. The Director of Nursing acknowledged noticing weight inconsistencies and attributed them to improper weighing practices. Another resident with multiple chronic conditions, including heart failure and chronic kidney disease, also had significant discrepancies in recorded weights, with large variations between measurements. The facility's policy required accurate and consistent weight measurement, including zeroing the scale and immediate recording, but the documented weights for this resident showed substantial differences within short timeframes. Staff interviews confirmed that unusual weight readings were to be reported, but the records did not reflect consistent adherence to these procedures.