Failure to Monitor and Record Resident Weight per Physician Orders and Policy
Penalty
Summary
The facility failed to monitor and record a resident's weight according to both physician orders and facility policy. Specifically, the resident, who had diagnoses including dependence on renal dialysis, critical illness myopathy, and type 2 diabetes mellitus with hypoglycemia and coma, was not weighed for eight days after admission, despite orders requiring weights on admission, daily for two days, weekly for three weeks, and then monthly. The facility's policy also required weights to be measured on admission, the next two days, and weekly for three additional weeks, with all weights recorded in the electronic health record. The nursing home administrator confirmed that these procedures were not followed for this resident. Additionally, the facility used an outdated weight from a previous admission, recorded over a year prior, to complete the resident's dietary assessment and to communicate with the dialysis provider. The resident's care plan identified them as being at risk for nutritional status changes due to infection and end stage renal disease, with interventions requiring weight monitoring and notification of significant changes. Despite this, the most recent and accurate weights were not used in clinical assessments or communications, as evidenced by the documentation reviewed by the surveyor.