Failure to Obtain and Document Monthly Weights as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document monthly weights for a resident as ordered by the physician. The physician's order specified that the resident was to be weighed monthly, but a review of the electronic health record showed that the last recorded weight was in June, with no weights documented for July or August. The resident's care plan identified them as being at risk for weight fluctuations and required weights to be taken per physician orders and facility protocol. The resident was cognitively intact and had a diagnosis of depression. Interviews with staff revealed that both nurses and CNAs were responsible for obtaining and documenting weights, and the MDS coordinator was tasked with ensuring weights were obtained according to orders. The MDS coordinator was new to the position, and the DON stated that if the resident had refused to be weighed, a progress note should have been made, but no such documentation was found. The lack of documented weights or refusals for two consecutive months constituted a failure to follow physician orders and facility protocol.