Failure to Monitor Weekly Weights for Malnourished Resident
Penalty
Summary
A resident with severe protein-calorie malnutrition, dementia with agitation, persistent mood disorders, and unspecified psychosis was admitted/readmitted to the facility from a geriatric psychiatric hospital. The resident was assessed as severely malnourished and underweight, with a physician's order for weekly weights for four weeks upon admission/readmission, a regular diet, and Ensure Plus twice daily as a supplement. The facility's policy and the Registered Dietitian's standard of practice also required weekly weight monitoring for newly admitted residents. However, a review of the electronic medical and treatment administration records revealed that weekly weights were not documented for the resident as required. Interviews with the DON and RD confirmed that the weekly weights were not completed according to the physician's order and facility policy. The DON acknowledged the omission, and the RD stated that she typically only monitored monthly weights, despite the requirement for weekly monitoring in this case. The facility's weight monitoring policy specified that newly admitted residents should have weights taken on admission and then weekly for four weeks, which was not followed for this resident.