Failure to Ensure Accurate and Consistent Weight Monitoring and Documentation
Penalty
Summary
A deficiency occurred when a resident with a history of leukemia, peripheral vascular disease, and transient ischemic attack did not receive care in accordance with professional standards regarding weight monitoring and documentation. Upon admission, the resident's weight was recorded as 89.4 lbs, but the following day, an LPN entered a weight of 113 lbs into the electronic medical record without notifying the physician of the significant discrepancy or requesting a reweigh. The initial admission weight was inactivated in the electronic record, making it inaccessible to other staff and absent from the nutritional assessment. Subsequent weights were inconsistently documented, with unclear dates and missing entries in both the weight book and electronic health record. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation, and that the dietitian review the weight record. However, there was no evidence that the dietitian addressed the admission weight discrepancy or the significant weight fluctuations in a timely manner. The dietitian relied on the 113 lbs value, disregarding the resident's report of a usual body weight under 100 lbs and the appearance of being underweight. When a later weight of 91.8 lbs was recorded, it was not promptly reweighed or entered into the assessment, and the dietitian continued to use the previous higher weight in documentation and care planning. Interviews with staff revealed inconsistent practices and lack of communication regarding weight monitoring. Certified Nurse Aides did not consistently document dates or initials for weights, and the process for reviewing and entering weights into the electronic record was unclear among nursing, dietary, and administrative staff. The medical director was not notified of significant weight changes and was unaware of missing or inaccurate weights in the resident's record. The lack of consistent, accurate, and timely weight monitoring and documentation led to the resident not receiving care in accordance with their needs and professional standards.