Failure to Obtain and Document Weekly Weights as Ordered
Penalty
Summary
The facility failed to ensure that weekly weights were obtained as ordered by physicians for two residents who were being monitored for nutritional status due to significant weight loss. For one resident with diagnoses including hemiplegia, dysphagia, cognitive impairment, depression, and severe protein calorie malnutrition, physician orders required weekly weights following a 14% weight loss over 180 days. Although weekly weights were signed off as completed in the Medication Administration Record (MAR), actual weight measurements were not documented for all required dates, and some weights were missing entirely from the medical record. This was confirmed by the Registered Dietitian. Similarly, another resident with Parkinson's disease, dementia, diabetes, anxiety disorder, and PTSD experienced a significant weight loss, prompting physician orders for weekly weights. The MAR indicated that weekly weights were signed off as completed, but actual weight measurements were only documented on two occasions, with no records for the other required dates. The Director of Nursing confirmed that weekly weights were not obtained as ordered. Facility policy required weights to be obtained monthly or as ordered by the physician, but this was not followed for these residents.