Failure to Document and Perform Weekly Weights for At-Risk Resident
Penalty
Summary
The facility failed to follow its policy on Weight Assessment and Intervention and did not adhere to physician orders for weekly weights for one resident. The resident in question was admitted with multiple diagnoses, including anemia, Type 2 diabetes, severe protein-calorie malnutrition, muscle weakness, dysphagia, and cognitive communication deficit. The resident's Minimum Data Set indicated severely impaired cognition and a therapeutic diet, with a care plan identifying risk for malnutrition and an intervention to be weighed as ordered. Physician orders specified weekly weights for four weeks, but documentation showed only an initial weight recorded on admission, with no further weights documented during the required periods. Interviews with facility staff, including a CNA, DON, and RD, confirmed that the only documented weight for the resident was on admission, and no evidence was provided to show that weekly weights were obtained as ordered. The facility's own policy required weights to be recorded upon admission and at intervals established by the interdisciplinary team or as ordered, with documentation in the medical record. The lack of documented weekly weights was confirmed through review of the electronic medical record, weight summary, and weekly weight sheets, as well as by staff interviews.