Failure to Revise Care Plan for Resident Refusing Daily Weights
Penalty
Summary
A deficiency was identified when the facility failed to revise the person-centered care plan interventions for a resident with congestive heart failure (CHF) who consistently refused daily weight monitoring. The resident was admitted with CHF and had a physician's order to notify the provider if there was a significant weight gain. Despite the care plan noting the risk for decreased ability to perform activities of daily living and resistance to daily weights, documentation showed that daily weights were not obtained on multiple days, and the resident's refusals were repeatedly documented in the nurse's progress notes. The resident, who had intact cognition and required assistance with mobility, expressed distrust in the accuracy of the Hoyer lift and wheelchair scales, leading to ongoing refusals to be weighed. Nursing staff acknowledged the resident's concerns and refusals, but the care plan was not updated to address these specific issues or to implement alternative interventions. The facility did not ensure that the care plan reflected the resident's preferences and refusals regarding weight monitoring, nor did it address the resident's concerns about the weighing equipment.