Failure to Consistently Monitor and Document Resident Weights and Nutrition Interventions
Penalty
Summary
The facility failed to consistently monitor and document residents' weights as required by their care plans, physician orders, and facility policy. Multiple residents, including those with significant medical histories such as cerebral palsy, diabetes, chronic heart failure, chronic kidney disease, malnutrition, and dysphagia, did not have monthly or weekly weights recorded as ordered. In several cases, there was no documentation of refusals, and staff interviews revealed confusion and inconsistency regarding the process for obtaining, recording, and following up on missing weights. For example, one resident was missing several months of weight documentation, and staff could not confirm or provide evidence of refusals, despite the resident stating they did not refuse to be weighed. Another resident experienced a significant weight loss of over 13% in just over two months, but weekly weights were not initiated until after family intervention. The care plan required offering food substitutes if less than 50% of a meal was consumed, but the resident reported not being offered alternatives and that their meal preferences were not documented on meal tickets. Staff interviews confirmed that likes and dislikes were not consistently recorded or communicated, and that interventions outlined in care plans were not always implemented. Additional deficiencies included a resident not being weighed upon admission despite hospital discharge instructions for daily weights due to heart failure, and another resident with a history of malnutrition and dysphagia not being weighed monthly, resulting in an unreported significant weight loss. The Registered Dietician and Nurse Practitioner both indicated that missing weights prevented them from accurately assessing nutritional status and implementing timely interventions. Facility policy required regular weight monitoring and prompt notification of significant changes, but these procedures were not reliably followed, leading to gaps in care and monitoring for multiple residents.