Failure to Monitor Resident Weights and Nutrition Status
Penalty
Summary
The facility failed to properly monitor the weight and nutritional status of two residents by not obtaining required weights or responding to weight changes as outlined in facility policy. According to the policy, residents are to have their weights recorded weekly for the first four weeks after admission or readmission, and monthly thereafter, with all weights transcribed into the electronic record. For one resident, there were no recorded weights for two consecutive months, despite the resident being identified as at nutritional risk and having diagnoses including hypertension, hyperlipidemia, and diabetes. For another resident, only two weights were recorded over an extended period, despite a care plan indicating the need for weight monitoring due to nutritional risk and diagnoses of anemia, hypertension, and depression. Staff interviews, including with the Director of Nursing, confirmed that the facility did not obtain the required weights or act upon changes in weight for these two residents. The deficiency was identified through a review of facility policy, clinical records, and staff interviews, and was cited under relevant state regulations for management and nursing services.