Failure to Document Required Resident Weights per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status by not following physician orders for regular weight monitoring. Specifically, the resident, who had multiple complex medical diagnoses including second-degree burns, COPD, type 2 diabetes, anemia, dependence on renal dialysis, major depressive disorder, and heart failure, was not weighed on a scheduled date as ordered by the physician. The resident's care plan included monitoring for alterations in nutrition and hydration, with specific interventions to track and report significant weight loss. However, review of the medical administration records and weight logs showed that the required weight measurement was not documented on the specified date. Interviews with staff revealed that weights were typically obtained by aides and then reported to a nurse for documentation, but in this instance, the process was not completed as required. The DON acknowledged that weights should have been documented to monitor the resident's progress, and the absence of this documentation meant that staff would not be aware of changes in the resident's condition. The facility's policy emphasized person-centered care and monitoring of unintended weight loss, but the failure to document the resident's weight as ordered constituted a deficiency in care.