Failure to Accurately Document and Monitor Resident Weights
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected the resident's condition and the care and services provided, as required by professional standards. Specifically, a resident admitted with a history of leukemia, peripheral vascular disease, and transient ischemic attack had inconsistent and inaccurate weights recorded in both the electronic medical record and on paper weight sheets. The initial weight recorded was 89.4 pounds, followed by a significant increase to 113 pounds, with subsequent weights fluctuating and not consistently documented in the electronic record. One weight of 91.8 pounds was only recorded on a weight sheet without a date and was not entered into the electronic medical record. The facility's policy required nursing staff to obtain weights on admission, for three consecutive days, and weekly thereafter, with the Registered Dietician responsible for reviewing and following up on weight trends. However, the process for obtaining and documenting weights was inconsistent, with Certified Nurse Aides recording weights on various days without always including the date, and not all weights being entered into the electronic record. The Registered Dietician did not follow up on discrepancies or ensure that reweighs were completed and documented, and did not include all relevant weights in their assessments. Communication regarding significant weight changes was not consistently documented or relayed to the medical team. Interviews with facility staff, including the Registered Dietician, Medical Director, Director of Nursing, and Administrator, confirmed that the system for monitoring and documenting weights was ineffective. Staff acknowledged that weights were not always obtained or recorded as required, and that there was a lack of clarity and consistency in the process. As a result, inaccurate information was reported to the medical team and the resident's representative, and a thorough nutritional assessment was not completed to address the resident's needs.