Delayed and Missed Reweights After Significant Weight Changes
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents by not completing timely reweights after significant weight changes were identified. For one resident, a discrepancy in weight was noted upon readmission, with an initial weight recorded at 181.3 pounds and a reweight not completed until 11 days later, confirming a weight of 135.0 pounds. Staff confirmed that the reweight was not performed promptly after the discrepancy was identified. For another resident, multiple significant weight changes were documented, including an 8.7% decrease and an 8.3% increase between monthly weights. In one instance, a reweight was not completed after a significant weight increase because the change did not trigger a reweight according to staff. In other instances, reweights were delayed, occurring 14 days and 5 days after the initial weight changes were identified. Facility policy required reweights to be completed the next day after a significant change, but this was not consistently followed.
Plan Of Correction
R4 is no longer in the facility. R22 has not needed a reweight since May 21, 2025. Residents requiring reweights will be reviewed daily by the dietician, and reweights will occur if there is a change of 5% or more since the last weight assessment. Reweights will be retaken the next day. Education will be completed by the DON/designee with all direct care employees and the interdisciplinary team to ensure that residents requiring reweights are completed timely. The dietician will review all weights per week for 4 weeks, then monthly for 2 months, to ensure reweights are being completed in a timely manner. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.