Failure to Accurately Document Resident Weights in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically by not documenting the resident's weights in the electronic medical record (EMR) for four out of five weeks during the review period. Although the facility's policy required new admissions to be weighed weekly for the first four weeks and for weights to be recorded in the EMR, the resident's weights were missing from the EMR for the weeks in question. The Director of Nursing (DON) acknowledged that weights were sometimes documented on paper and not entered into the EMR, citing being short-staffed as a reason for the omission. The administrator confirmed that the facility's weight monitoring reports relied on data entered into the EMR, and missing entries could affect the facility's ability to detect weight changes. The resident involved was an older male with a history of cerebral infarction, muscle wasting, atrophy, and lack of coordination. He was at moderate risk for malnutrition, obese, and at risk for weight changes due to edema and diuretic use. The resident's progress notes and nutritional therapy evaluation did not contain alternative documentation of weights for the missing weeks. Handwritten records were available but not consistently dated or entered into the EMR as required by facility policy. This incomplete documentation was identified through observation, interviews, and record reviews.