Failure to Document Resident Weight Refusals and Monitoring
Penalty
Summary
The facility failed to document the completion and/or refusal of weights for one resident reviewed for nutrition. The resident was admitted alert and oriented, but their care plan did not include any identified problems or goals related to nutrition or hydration. The electronic health record (EHR) showed several recorded weights over a two-month period, but staff interviews revealed that the resident often refused to be weighed. Despite this, there was no documentation in the EHR progress notes regarding the resident's refusals. Certified Nursing Assistants (CNAs) were responsible for obtaining weights and reporting them to nursing staff, who then entered the data into the EHR. Both nursing and dietary staff confirmed that refusals should be documented in the EHR progress notes, and that the process included educating the resident on the risks and benefits of refusing weights. However, a review of the EHR found no documentation of weight refusals for this resident, indicating a failure to follow established procedures for documenting refusals and monitoring nutritional status.