Failure to Obtain Weights and Provide Recommended Nutritional Supplement
Penalty
Summary
The facility failed to obtain required admission weights for a resident with significant medical conditions, including non-traumatic subarachnoid hemorrhage, cerebral aneurysm, hemiplegia/hemiparesis, and dysphagia. Although physician orders specified that admission weights should be taken for three days, only one weight was documented, and no further weights were recorded until nearly two months later. The resident's care plan also called for weekly weights, but these were not completed as required. Additionally, the dietician recommended a nutritional supplement (Benecalorie) three times daily due to the resident's poor intake and risk for weight loss. However, this recommendation was not forwarded to the physician for an order, and the resident did not receive the supplement. Documentation from the nutrition team repeatedly requested updated weights to confirm adequacy of intake, but these requests were not fulfilled. The DON acknowledged these failures during an interview.