Failure to Obtain Weekly Weights for Residents with Feeding Tubes
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice by not obtaining weekly weights as ordered by physicians for three residents with feeding tubes. Clinical record reviews, staff interviews, and policy review revealed that physician orders for weekly weight monitoring were not followed for these residents, despite their high risk for nutritional issues due to conditions such as malnutrition, anemia, diabetes, traumatic brain injury, cerebrovascular accident, and respiratory failure. Care plans for these residents specifically identified the need for close nutritional monitoring, including regular weights, due to their dependence on tube feeding and other complex medical needs. For one resident, only a single weight was documented in the month of May, despite a physician order for daily weights for three days followed by weekly weights. Progress notes indicated significant weight fluctuations and insufficient documentation of weights, with the dietician noting the lack of weekly weights and recommending changes to tube feeding due to observed weight loss. Another resident had multiple missed weekly weights over several months, as shown in the weight summary and treatment administration records. Staff interviews confirmed ongoing issues with obtaining accurate and timely weights, with equipment problems and staff performance cited as contributing factors. A third resident with multiple complex medical diagnoses, including muscular dystrophy, respiratory failure, and malnutrition, also had physician orders for daily and weekly weights that were not consistently followed. Medication administration records and weight logs showed only sporadic documentation of weights over a two-month period. Facility policy required implementation of a weight monitoring schedule and timely recording of weights, but this was not adhered to for these residents, resulting in a failure to meet professional standards of quality for monitoring nutritional status.