Failure to Implement Daily Weight Monitoring for Resident with Malnutrition
Penalty
Summary
The facility failed to implement physician's orders for daily weight monitoring for a resident with a diagnosis of malnutrition, anemia, hip fracture, difficulty swallowing, and multiple pressure ulcers. The resident was admitted with a care plan that required daily weights, monitoring for signs of malnutrition, and reporting significant weight loss to the medical doctor. Despite these orders, the medical record showed only three weights documented over a two-week period, with no evidence of daily weight checks as required. The resident's condition was complex, including a history of poor nutrition, substance abuse, past gastric bypass, and ongoing wounds requiring increased protein intake. The resident was on a mechanical soft diet, received nutritional supplements, and had orders for a low sodium diet and diuretic therapy for edema. Staff interviews revealed that the resident typically ate 50-75% of meals, had difficulty swallowing due to missing teeth, and was considered frail by staff. However, staff did not notice any significant weight loss, and the registered dietician's notes did not provide direction for weight monitoring. Hospital records indicated a significant weight loss between the last documented facility weight and the hospital admission weight, with a drop from 101.1 lbs. to 77 lbs. within a short period. The facility's director of nursing acknowledged that staff failed to enter the daily weight orders correctly, resulting in the lack of daily weight monitoring. The facility's weight policy required accurate and regular weight monitoring to prevent avoidable decline in nutritional status, but this was not followed for the resident in question.