Failure to Obtain Weekly Weights for At-Risk New Admission
Penalty
Summary
The facility failed to obtain weekly weights for a newly admitted resident who was identified as being at nutritional risk. Upon admission, the resident had multiple significant diagnoses, including spinal fusion, various malignant neoplasms, bacteremia, and acute kidney failure. The initial nutritional evaluation recommended monitoring weights, and the care plan identified the resident as being at risk for nutritional issues and dehydration due to cancer, corticosteroid use, and obesity. Despite these risk factors and facility policy requiring weekly weights for new admissions, only two weights were recorded over a one-month period, showing a significant weight gain of 25.1 pounds (13.4%). Interviews with the registered dietitian and the DON confirmed that weekly weights were not ordered or obtained as required. The DON stated that certified nursing assistants were responsible for obtaining weights as ordered, but there was no order for weekly weights upon admission. The facility's weight management policy specified that residents should be weighed upon admission and weekly for four weeks, but this was not followed for the resident in question.