Failure to Obtain and Document Weekly Weights and Re-Weights as Ordered
Penalty
Summary
Staff failed to obtain and document weekly weights and re-weights as ordered by the physician for a resident with multiple complex medical conditions, including sepsis, chronic osteomyelitis, a stage 4 pressure ulcer, and a urinary tract infection. The physician's order specified that weights should be obtained on admission and then weekly for four weeks, but documentation showed that after the initial admission weights, subsequent weekly weights were missing for several weeks. The Medication Administration Record indicated that weights were signed off as completed, but no actual weight values were recorded for some dates, and there were significant gaps in the weight documentation. The resident's care plan identified a risk for malnutrition due to variable intake, obesity, and a pressure wound, with interventions including monitoring and evaluating weight and weight changes. Despite this, there were multiple instances where significant weight loss occurred, including a 10.1-pound loss between admission and the next recorded weight, and a 10.2-pound loss over six days, without timely re-weighs to confirm accuracy. The facility's policy required re-weighs to verify significant weight changes, but these were not consistently performed or documented. Interviews with staff, including the dietician, RN, and DON, confirmed that weights were missing and that the process for obtaining and verifying weights was not consistently followed. The lack of timely and accurate weight monitoring and re-weighs as ordered by the physician and required by facility policy contributed to the deficiency in ensuring adequate nutrition and hydration monitoring for the resident.