Failure to Obtain and Document Weekly Weights and Prompt Re-Weight After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document weekly weights for a resident at risk for weight loss, as ordered by the physician. The resident, who had diagnoses including adult failure to thrive, anorexia, dysphagia, and type II diabetes mellitus, was identified as being at risk for malnutrition due to poor intake and low albumin levels. Despite physician orders for weekly weights and care plan interventions to monitor weight, there was no documentation of weights being obtained on several scheduled dates, even though the Medication Administration Record (MAR) was signed off as if the weights had been taken. When a significant weight loss of 26.2 pounds in one week was documented, the facility failed to obtain a re-weight promptly to confirm the accuracy of this change. The re-weight was not performed until seven days later, and the dietician did not follow up on the significant weight loss until ten days after it was first identified. Interviews with staff revealed confusion and lack of clarity regarding responsibility for obtaining and documenting weights, as well as the absence of a facility policy on when to perform re-weights after significant changes. Further review showed that the MAR allowed nurses to sign off on weights without entering the actual measurement, and there was a period when the facility did not have a dietician on staff, resulting in a lack of interdisciplinary review of triggered weights. The facility's weight monitoring policy required timely recording and comparison of weights, but this was not followed, leading to a delay in identifying and responding to the resident's significant weight loss.