Failure to Ensure Accurate Resident Weights Due to Scale and Staff Errors
Penalty
Summary
The facility failed to ensure that resident weights were taken appropriately and verified as accurate according to professional standards of nutritional practice. One resident, who was thin in stature and had a history of loose dentures affecting their ability to chew, was observed with discrepancies in their recorded weights. The resident's electronic medical record showed a significant and atypical weight change of nearly 40 pounds over a two-week period, with weights fluctuating between 183.8 pounds and 144.4 pounds. The initial dietary assessment and hospital records also showed inconsistencies between the hospital discharge weight and the facility admission weight, which were not accurately reconciled at the time of admission. The facility's process for obtaining and documenting weights was inconsistent, with weights being recorded in both standing and sitting positions and by different staff members. There was no clear policy guidance on referencing hospital weights upon admission, calibrating scales, or ensuring consistency in weighing methods. The registered dietician acknowledged that scale discrepancies and staff inconsistencies contributed to the inaccurate weights, and that the issue was not identified until significant weight fluctuations were observed in multiple residents. The Director of Nursing confirmed that two of the facility's standard scales were found to be inaccurate, and that a staff member had been weighing residents incorrectly. These issues led to widespread inaccuracies in resident weight records, which were only discovered after significant fluctuations were noted. The facility's policy did not address the need for scale calibration or specific procedures for addressing weight inconsistencies, contributing to the deficiency.