Failure to Obtain Weekly Weights and Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to ensure that a resident's weights were obtained as ordered and that the physician was notified of significant weight changes, as required by physician orders and facility policy. The resident, who had diagnoses including dysphagia, dementia, gastro-esophageal reflux disease, and hypertension, was admitted with an order for weekly weights and physician notification if her weight changed by more than three pounds from her admission weight. Despite this, there were multiple instances where weights were not recorded weekly, and significant fluctuations in weight were not consistently communicated to the physician. Review of the resident's weight records showed irregularities, including periods where no weights were documented for several weeks, and instances where reweights were requested but not completed in a timely manner. Notably, there was no weight recorded between early May and late May, despite a request for a reweight. The resident experienced both significant weight gains and losses over short periods, but documentation did not show that the physician was notified each time the weight change exceeded the threshold specified in the order. Interviews with facility staff, including the dietitian and nursing leadership, confirmed that the weekly weights and required notifications were not consistently performed. Staff were unclear about who was responsible for notifying the physician and could not provide evidence that notifications occurred as ordered. The care plan also did not reflect the specific order for weekly weights and physician notification for significant weight changes, further contributing to the deficiency.