Inaccurate Weight Documentation in Resident Medical Record
Penalty
Summary
The facility failed to accurately document a resident's weight in the medical record, resulting in inconsistencies and incorrect clinical data for one of the sampled residents. Specifically, the resident's weight was recorded as 76.7 pounds on one date, while two days earlier it was documented as 167.2 pounds. Additionally, another set of weights showed a significant discrepancy, with 159.5 pounds recorded on one date and 189 pounds five days later. These errors were confirmed by both the Director of Nursing and a Registered Nurse, who identified that the weights were entered incorrectly in the electronic medical record by different LPNs. The inaccuracies led to the system incorrectly triggering weight alerts, which did not reflect the resident's actual clinical status. The resident involved had been admitted with diagnoses including heart failure, and the Minimum Data Set assessment indicated a significant weight loss over the review period. The errors in weight documentation were not identified at the time of entry, resulting in inaccurate information being maintained in the resident's medical record. The facility's process for reviewing weights was not sufficient to prevent or promptly correct these documentation errors.