Failure to Obtain Weekly Weights After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain weekly weights for a resident who experienced a significant change in condition, specifically a weight loss of 15 pounds in one week. The resident had been admitted with diagnoses including hypertensive heart disease with heart failure, muscle weakness, and polyneuropathy. The care plan, created and revised after the weight loss, included interventions such as weekly weights and monitoring for changes in condition, but these interventions were not consistently implemented. The resident's weight dropped from 157 lbs. to 142 lbs. within eight days, representing a 9.6% loss. Despite the care plan and interdisciplinary team notes indicating the need for weekly weights, the next documented weight was not obtained until nearly two weeks later. During this period, the resident developed edema in both lower extremities and upper arms, and a subsequent weight measurement showed a significant increase, which was not immediately recorded due to concerns about accuracy. The facility's own policy required weekly weights for new admissions and for residents with significant weight changes, but this was not followed. Interviews with the ADON and DON confirmed that weekly weights were not performed as required for the resident, and both acknowledged that this lapse could have led to a delay in care. The facility's policy and the care plan both specified the need for weekly monitoring, but the failure to obtain and document these weights resulted in a deficiency related to maintaining adequate nutrition and hydration for the resident.