Failure to Monitor and Document Resident Weights and Nutrition Status
Penalty
Summary
The facility failed to properly monitor the weight and nutritional status of two residents by not obtaining weights as ordered and not acting upon significant weight changes. For one resident with diagnoses including COPD, diabetes, and dementia, the care plan did not include goals or interventions related to nutrition. Despite physician orders to obtain monthly weights, there were missed weight recordings on multiple occasions, with nursing notes indicating the task was not done or staff were too busy. Additionally, a dietitian's order for special weight monitoring was not carried out, and a subsequent physician order to obtain and document weight was also not completed. For another resident with lymphedema, morbid obesity, and hypertension, the care plan required weight monitoring and notification of the physician for significant weight changes. However, weight documentation was inconsistent, with several missed entries due to resident refusal, equipment issues, or lack of documentation. The facility's failure to consistently obtain and document weights, as well as to act upon notable weight changes, was confirmed by the Nursing Home Administrator during an interview.