Failure to Weigh Resident Upon Readmission Delays Nutrition Management
Penalty
Summary
The facility failed to follow its policy and procedure for Nutrition Status Management by not weighing a resident upon readmission, which delayed the identification and management of significant weight loss. The resident, who had a history of atherosclerosis, coronary artery bypass grafts, UTI, and sepsis, was moderately cognitively impaired and dependent on staff for several activities of daily living. Upon readmission, physician orders required weekly weights and nutritional supplements, but the resident was not weighed until six days after readmission. The Registered Dietitian did not conduct a nutrition evaluation or identify the resident's weight loss until this delayed weigh-in occurred. Record reviews and staff interviews confirmed that the initial weight was not documented in the electronic health record as required by facility policy. The resident experienced a notable decrease in weight over a short period, and the delay in weighing resulted in a late response to her nutritional needs. Both nursing and dietary staff acknowledged that earlier intervention could have occurred if the weight had been taken and reviewed as per protocol. The facility's policy clearly stated that residents are to be weighed upon admission, but this was not followed in this instance.