Failure to Obtain and Monitor Accurate Admission Weight
Penalty
Summary
The facility failed to obtain an accurate admission weight and did not ensure ongoing accurate weight monitoring for one resident. According to facility policy, new and re-admission residents are to have their weight and height obtained within 24 hours of admission, and significant weight changes are to be reported to the Registered Dietitian and the physician. For one resident with diagnoses including stroke, dysphagia, tracheostomy dependence, and PEG tube feeding, the admission weight was inaccurately documented, and subsequent weights were also incorrect and later struck from the record. As a result, the resident's nutritional status and tube feeding regimen were based on inaccurate weight data for nearly a month, making it impossible to determine if there was a significant weight loss during that period or if the tube feeding was adequate. The issue was confirmed through clinical record review and staff interview, which revealed that the initial and subsequent weights were not accurate, and the error was only identified after receiving a hospital weight.