Failure to Perform Weekly Weights and Notify Staff of Poor Intake
Penalty
Summary
The facility failed to perform weekly weights as ordered and per the care plan for one resident with significant medical conditions, including metabolic encephalopathy and a second-degree burn due to heatstroke. The resident was admitted with an order for weekly weights for four weeks, and the care plan also specified this intervention. However, documentation showed that weights were not consistently recorded on a weekly basis, with gaps of 8 to 18 days between some weight entries. There was no documented weight for one of the scheduled weeks, and no follow-up documentation was provided regarding the missed weight. Additionally, the resident's nutritional intake was below expectations, with meal consumption often at 26-50% for breakfast and lunch. Despite this, there was no evidence in the progress notes that licensed nurses were notified when meal intakes were low or when meals were refused, as required. Interviews with staff confirmed that the expectation was to follow orders and care plans, and to report changes in condition or poor intake, but there was no policy outlining the communication process between CNAs and licensed nurses for such concerns. The facility's own policy required weekly weights for four weeks upon admission, which was not followed in this case.