Missed Weekly Weight Monitoring for Resident
Penalty
Summary
The facility failed to follow a physician's order to conduct weekly weights for a resident who was admitted with diagnoses including type 2 diabetes, muscle weakness, and metabolic encephalopathy. The resident was dependent on staff for activities of daily living and had cognitive impairments, as documented in the admission records and assessments. The physician's order, dated 4/21/2025, specified that the resident's weight should be monitored weekly for 30 days. However, a review of the weight records showed that after an initial weight was recorded on 4/22/2025, the next weight was not documented until 5/4/2025, with no weight recorded on 4/29/2025 as required by the order. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that the weekly weight was missed and acknowledged that this was not acceptable practice. The facility's policy on weighing and measuring residents, last reviewed on 1/20/2025, emphasizes the importance of regular weight monitoring as an indicator of nutritional status. The failure to obtain and document the weekly weight as ordered resulted in a deficiency related to the monitoring of the resident's nutritional status.