Failure to Ensure Accurate and Complete Weight Documentation
Penalty
Summary
The facility failed to ensure that the medical record, specifically the documentation of resident weights, was complete and accurate for two residents. For one resident with diagnoses including cirrhosis of the liver, major depressive disorder, and enterocolitis due to clostridium difficile, there were significant discrepancies in the recorded weights over several months. The Minimum Data Set (MDS) did not indicate any weight gain or loss, but the documented weights varied widely, with one notably low weight not addressed or explained in the medical record. There was no evidence in the progress notes that staff acknowledged or investigated the low weight, nor was there documentation of staff notifying the physician or dietician of this abnormal finding as required by the care plan and physician orders. Interviews with staff revealed inconsistent practices and a lack of standardized procedures for obtaining and recording weights, particularly when using a Hoyer lift with a scale. Certified Nursing Assistants (CNAs) and Restorative Nursing Assistants (RNAs) reported varying methods, such as subtracting an estimated weight for the sling, which was not supported by facility policy. Staff also indicated insufficient training on proper weighing techniques, and some expressed concern that many staff did not know the correct procedures, potentially leading to inaccurate documentation. The Diet Technician and Nurse Supervisor both stated that re-weighs should be performed if a weight appears abnormal, but there was no clear timeframe or documentation of this process being followed in the case reviewed. Facility policy required significant weight changes to be reported to the nurse supervisor and outlined procedures for weighing residents using various types of scales, but did not address the use of a Hoyer lift with a scale. The Director of Nursing (DON) and Assistant DON acknowledged that the low weight recorded was likely an error but could not find any documentation that it was addressed or confirmed as inaccurate. The attending physician was not notified of the abnormal weight and stated that such discrepancies could affect resident care, especially for those with conditions requiring close weight monitoring.