Failure to Accurately Monitor and Document Resident Weight and Food Intake
Penalty
Summary
The facility failed to ensure the accuracy of a resident's weight and to monitor the resident's food intake as required by the care plan. The resident, who had diagnoses including Alzheimer's disease, dementia with psychotic disturbances, and type 2 diabetes, was noted to have severely impaired cognition and behavioral symptoms. The resident's weight records showed a decline from 162 lbs to 147 lbs over several months, with one weight entry being crossed off by the Registered Dietician (RD) due to concerns about its accuracy. The RD did not document re-weights in the electronic medical record (eMR), and the re-weight information was not accessible to other staff, as it was kept in the RD's office and not entered into the eMR. Interviews with staff revealed that weights were obtained by CNAs and entered into a weight binder, with the RD providing lists of residents needing re-weights. However, the Assistant Director of Nursing (ADON) confirmed that these records were not part of the official medical record, and that weights and re-weights should have been available in the eMR for review by ancillary providers. This lack of documentation meant that weight variances were not thoroughly investigated or accessible to all relevant staff. Additionally, the care plan for the resident included monitoring oral intake as needed, but review of the electronic point-of-care system (POCS) showed significant gaps in documentation. For two consecutive months, the majority of shifts lacked documentation of the percentage of meals consumed by the resident, with only a small fraction of shifts having this information recorded. Facility policies required CNAs to monitor and document dietary intake for each meal, but this was not consistently done, contributing to the deficiency.