Failure to Timely Obtain and Confirm Weights for Residents with Significant Weight Changes
Penalty
Summary
For one resident with dysphagia, dementia, diabetes, and anxiety, the facility failed to reweigh the individual after a significant weight loss. The care plan required weekly weights and the physician's order specified weekly weights on a particular shift. Documentation showed a loss of 10.2 lbs. in one week, but there was no evidence in the clinical record that a reweight was performed or refused after this significant loss. Nursing staff confirmed that the resident was not reweighed and could not provide a reason for this omission. The dietician was not notified of the weight loss until approximately two weeks later, and the Director of Nursing Services (DNS) was unable to confirm if any attempts to reweigh the resident were made. For another resident with a gastrostomy tube and a diagnosis of malignant neoplasm of the tongue and adult failure to thrive, the facility failed to obtain a timely admission weight and did not reweigh the resident after a significant weight loss. The care plan and physician's order required an admission weight and weekly weights for four weeks. However, the admission assessment did not include a weight, and the dietician's nutrition assessment noted the admission weight as pending. Nursing staff were unaware that the admission weight had not been obtained until prompted by surveyors, and the weight was only recorded three days after admission, showing a 6.95% loss from the hospital weight. There was no documentation of a reweight after this significant loss. Facility policy required weights to be obtained on admission, the next day, and weekly for four weeks, with any weight change of 5% or more to be retaken the next day for confirmation and immediate notification of the dietician. In both cases, these procedures were not followed, as weights were not obtained or confirmed in a timely manner, and appropriate notifications were not made.