Failure to Accurately Monitor Weights and Implement Dietitian Recommendations
Penalty
Summary
The facility failed to ensure accurate and timely weight monitoring, identification, and reporting of significant weight loss, as well as failed to implement dietitian recommendations for multiple residents. For one resident with multiple diagnoses including anemia, hypertension, and pressure ulcers, significant weight loss occurred over a short period without notification to the Registered Dietitian (RD). The RD was not informed of the weight change, and there were concerns about the accuracy of the weights recorded. The resident's care plan required regular weight monitoring and prompt reporting of significant changes, but these protocols were not followed. Another resident with severe cognitive deficits and a history of malnutrition and pressure wounds was not weighed upon readmission from the hospital, contrary to facility policy requiring daily weights for the first three days post-admission. The RD was unable to assess for significant weight loss due to missing weights, and scheduled weekly weights were not documented in the electronic record. The lack of timely and accurate weight documentation prevented the RD from making necessary nutritional assessments and interventions. Additional residents experienced similar deficiencies. One resident with Alzheimer's and a history of pressure ulcers and hip fracture had a documented 14.3% weight loss over two months, with a missing monthly weight that was not entered into the electronic health record as required. Another resident with a history of fluctuating weights and multiple diagnoses did not receive a recommended nutritional supplement because the RD's recommendation was not converted into a physician order, resulting in the intervention not being implemented. Facility policies required regular weight monitoring, reweighs for significant changes, and prompt communication of RD recommendations, but these were not consistently followed.