Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure that resident weights were consistently monitored and that significant weight changes were promptly addressed for five out of fifteen residents reviewed. According to the facility's policy, any weight change of 5% or more should be retaken the next day for confirmation, and if verified, nursing should notify the dietitian. However, for several residents, there were missed or delayed weight recordings, and required reweights were not obtained as per policy. For example, one resident experienced a 9.4% weight loss over two weeks, but a confirming weight was not obtained until nine days later, and subsequent monthly weights were missed. Another resident had a 9.34% decrease in weight, but staff did not retake the weight the following day as required. Additional residents had missing monthly weights for various months, and in one case, the last recorded weight was several months prior to the review. Staff interviews confirmed that the standard practice is to weigh residents monthly and to obtain reweights within 72 hours if significant changes are noted. Despite these standards and physician orders specifying monthly weights, the facility did not consistently follow through with timely weight monitoring or documentation. The Nursing Home Administrator confirmed these findings during interviews, and the deficiencies were cited under relevant state patient care and nursing services regulations.