Failure to Monitor and Document Weights for Resident on Enteral Nutrition
Penalty
Summary
Staff failed to consistently monitor and document the weight of a resident who was dependent on enteral nutrition due to a persistent vegetative state. The resident's care plan and physician orders required weekly weights to be obtained and recorded, particularly given the resident's risk factors such as swallowing issues, enteral diet, and the presence of a pressure ulcer. Despite these directives, there were multiple instances where weights were either not obtained or not documented in the electronic medical record. On several occasions, nurses indicated that the resident was weighed, but no actual weight was recorded, and on other dates, the weight was not obtained at all. The resident's medical record showed a gradual decrease in weight over several months, with a notable drop from 153.3 pounds to 144.6 pounds. Interviews with nursing staff and administrative personnel confirmed that weights should have been obtained at least weekly for residents receiving enteral feedings. The facility's own competency guidelines for administering enteral feedings also required weights to be taken daily or three times a week as appropriate. The failure to consistently monitor and document the resident's weight as ordered placed the resident at risk for continued weight loss and malnutrition.