Failure to Obtain Actual Admission Weight for Resident
Penalty
Summary
Facility staff failed to obtain an actual weight for a resident upon admission, instead recording a weight copied from preadmission hospital records. The resident, who had diagnoses including diabetes mellitus, dysphagia, and acute kidney failure, was identified as being at risk for nutritional and hydration issues, with interventions in place to monitor and prevent weight loss. The care plan and Minimum Data Set assessment indicated the resident required maximum assistance with eating and had impaired cognition. Upon review, the Registered Dietitian determined the recorded admission weight was inaccurate and confirmed with the admitting RN that no actual weight was obtained at the time of admission. Interviews with the RN, RD, and DON confirmed that facility policy requires staff to obtain and document an accurate admission weight using appropriate equipment, and that staff should not use hospital weights or self-reported weights. The failure to obtain an actual admission weight was acknowledged by all interviewed staff and was contrary to facility policy.