Failure to Obtain and Document Weights per Policy for Resident with Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document resident weights according to its own policy for a resident with a history of weight loss and multiple risk factors, including obesity, dysphagia, and aphasia. The resident experienced significant weight loss over a period of weeks, with electronic records showing a drop from 155.0 pounds to 147.6 pounds, and later to 140.0 pounds. Despite these changes, no reweight was obtained within 24 hours to verify the weight loss, as required by facility policy. Additionally, a readmission weight was not obtained within 48 hours after the resident returned from the hospital, and the first weight post-readmission was documented six days later, two days after the dietician requested it. The facility's policy required prompt reweighing and documentation in cases of unplanned weight loss or gain of 5 pounds or more, as well as timely notification to the physician and updates to the care plan. However, interviews and record reviews revealed that the responsible RN was unaware of the missed weights and did not monitor weights after hospital readmissions. There was also no documentation that the physician was notified of the significant weight loss, nor evidence that the care plan was adjusted in response to these changes.