Failure to Obtain and Document Daily Weights for Dialysis Residents
Penalty
Summary
The facility failed to obtain and document daily weights as ordered by physicians for residents receiving dialysis treatment. Specifically, three residents with end-stage renal disease and dependence on dialysis were identified as not having their weights recorded on multiple days, despite physician orders and care plans requiring daily weight monitoring. Medical record reviews showed several missed weight entries for each resident over a period of weeks, and interviews with staff and residents confirmed that weights were not consistently obtained as required. Residents affected had significant medical histories, including end-stage renal disease, pleural effusion, congestive heart failure, and other comorbidities, and required close monitoring due to their dialysis needs. The facility's own policy mandated daily weights for these residents, yet documentation revealed repeated lapses. Staff interviews indicated that weights were sometimes missed due to workload and staffing assignments, and residents themselves reported not being weighed daily before or after dialysis sessions.