Failure to Obtain Re-Admission Weight as Ordered
Penalty
Summary
The facility failed to measure a resident's weight upon re-admission as required by both physician order and facility policy. The resident, an elderly male with severe cognitive impairment and multiple diagnoses including pneumonitis due to aspiration, COPD, dysphagia, heart failure, and edema, was re-admitted with a physician order specifying that his weight should be measured upon admission/re-admission and weekly for four weeks. However, review of the resident's records showed that no weight was recorded on the re-admission date, and the first weight measurement was not taken until several days later. The care plan also indicated the need for close monitoring of weight due to the resident's medical conditions and risk factors. Interviews and documentation confirmed that the nurse responsible for the re-admission assessment did not obtain the resident's weight as ordered. The ADON stated that the nurse was an agency nurse who was no longer employed at the facility and could not provide a reason for the omission. Facility policy required weights to be taken at admission, re-admission, and per physician orders, but this protocol was not followed in this instance, resulting in a failure to ensure the resident's nutritional status was adequately monitored at a critical time.