Failure to Obtain and Document Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain and document resident weights in accordance with physician orders and facility policy for two residents reviewed for nutrition. One resident with end stage renal disease, diabetes, heart failure, and chronic obstructive pulmonary disease had a physician order for daily weights due to congestive heart failure, but multiple days were identified across several months where weights were not obtained as ordered. The Director of Nursing confirmed that these weights were missed, and facility policy required weights to be recorded at intervals established by the interdisciplinary team. Another resident with parkinsonism and moderate protein-calorie malnutrition experienced a significant weight loss of 14 pounds (11.4%) over a one-month period. The dietitian was aware of the weight change and requested a reweight, but this was not completed within the expected 48-hour timeframe. The resident reported not being reweighed after the initial weight loss was identified, and there was no evidence in the medical record that the dietitian had acknowledged the weight change or that a timely reweight was performed, as required by facility policy.