Failure to Obtain and Document Weekly Weights and Reweight for Resident with Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders for obtaining weekly weights and a reweight for a resident with significant weight loss. The resident, who had diagnoses including dysphagia, aphasia, and type 2 diabetes mellitus, was admitted with a care plan that identified risks for weight loss and required weekly weights on shower days. Despite these orders, documentation showed that weights were only recorded on two occasions over a period of several weeks, revealing a severe weight loss of 20.8 pounds (14.4%) in two weeks. Additionally, a physician's order for a reweight to verify this loss was not carried out as directed. Interviews with staff confirmed that nurse aides were responsible for obtaining weights and nurses were to check and transcribe them into the electronic health record. However, review of records and staff interviews indicated that the required weekly weights and the ordered reweight were not completed as per protocol. The facility's policy also required retaking weights after significant changes and notifying the dietician, but these steps were not documented as completed at the time of the survey.