Failure to Implement Weekly Weight Monitoring per Dietitian Recommendation
Penalty
Summary
The facility failed to implement a Registered Dietitian's recommendation to obtain weekly weights for a resident with chronic kidney disease, hypertension, and prostate cancer. The resident was admitted with orders for a cardiac diet and a mechanically altered diet. The care plan identified nutritional risks and included interventions such as monitoring for significant weight loss and following the Registered Dietitian's recommendations. Despite these interventions, the resident's electronic health record showed inconsistent and missing weekly weight documentation over several weeks following admission, contrary to both facility protocol and the Registered Dietitian's explicit instructions. Interviews with facility staff, including the MDS Coordinator, Registered Dietitian, Nurse Practitioner, and Assistant Director of Nursing, confirmed that weekly weights were expected for new admissions and that the responsibility for implementing the Registered Dietitian's recommendations rested with the MDS Coordinator and ADON. However, the staff were unable to explain why the weekly weights were not obtained as required, and the oversight resulted in a failure to monitor the resident's nutritional status as planned.