Failure to Monitor and Document Resident's Weekly Weights as Ordered
Penalty
Summary
The facility failed to ensure that nutritional orders for a resident were properly monitored and completed. Specifically, a resident with multiple diagnoses, including schizoaffective disorder, dementia, dysphagia, and muscle weakness, had a physician's order in place for weekly weight checks starting from a specified date. There was no documented end date for this order, nor any recommendation or order from the dietitian or physician to discontinue the weekly weights. Despite this, the resident's weight was not recorded on several required weeks, and there was a significant gap of nearly a month with no weight documentation. Review of the facility's nutrition protocol indicated that nursing staff are required to monitor and document residents' weights and dietary intake in a manner that allows for comparison over time. The protocol also requires ongoing monitoring and documentation of nutritional status and interventions. Interviews with the DON confirmed that the weekly weight order was still active and that there was no documentation to support discontinuation. The missing weight records were acknowledged as not completed, indicating a failure to follow the physician's order and facility policy.