Failure to Obtain and Document Admission and Weekly Weights
Penalty
Summary
The facility failed to weigh one of three residents on admission and weekly for four weeks as required by its policy and procedure titled 'Weight Assessment and Interventions.' Specifically, the resident was not weighed upon readmission, and there were no recorded weights for the required weekly intervals following readmission. The resident's care plan included an intervention to monitor weight per policy due to a diagnosis of cellulitis of the right lower limb and acquired absence of other right toe(s). Despite this, the weight records did not include a weight taken on the day of readmission, nor were there documented reasons in the progress notes for missing weights on subsequent required dates. Interviews with facility staff, including an LVN, RN, and the DON, confirmed that the facility's policy was not followed, as weights were not obtained or documented as required. The DON acknowledged the absence of weight records and progress notes explaining the missed weights, and confirmed the importance of obtaining weights on admission to monitor residents' health status. The facility's policy clearly stated that weights should be measured on admission, the next day, and weekly for four weeks, and recorded in the appropriate records, which was not done in this case.