Failure to Obtain and Document Resident Weight Upon Readmission
Penalty
Summary
The facility failed to obtain a weight for a resident upon readmission from the hospital and did not document any refusal to be weighed. The resident, who had diagnoses including metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity, was dependent on staff for activities of daily living and had intact cognition. The last recorded weight for the resident was 536 pounds, taken prior to the hospital stay. Upon readmission, the nursing admission assessment and progress notes did not include a new weight or any documentation of the resident refusing to be weighed. Additionally, there were no physician orders for weight monitoring frequency following the resident's return from the hospital. The facility's policy required residents to be weighed within 24 hours of admission or readmission, then weekly for four weeks, and monthly thereafter, with all weights to be recorded and trended in the medical record. The Director of Nursing confirmed that no weight was obtained and no refusal was documented as required by policy.