Failure to Document Resident Weight in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting the resident's weight in the Point Click Care (PCC) system for July 2025. The resident, a female with diagnoses including unspecified dementia, major depressive disorder, diabetes, and hypertension, had a moderate cognitive impairment as indicated by a BIMS score of 8. Although the resident's weight was taken on July 8, 2025, the ADON, who was responsible for entering this information, did not document it in PCC. The omission was only discovered when the resident was discharged on July 19, 2025. Interviews with the ADON, DON, and ADM confirmed that it was the facility's expectation for the weight to be documented in PCC by July 10, 2025. The facility's policy requires all clinical documentation, including weights, to be recorded accurately and in a timely manner in the resident's medical record. The failure to document the weight meant that the system could not flag any significant weight changes, which are necessary for identifying and addressing potential health concerns.