Failure to Accurately Monitor and Record Resident Weights Resulting in Unaddressed Significant Weight Loss
Penalty
Summary
The facility failed to monitor and accurately record the weights of a resident with Alzheimer's disease, resulting in a significant, unaddressed weight loss. The resident was admitted at a weight of approximately 205 pounds and was noted to have severe cognitive impairment. Over a period of several weeks, staff, specifically a CNA, falsified weight documentation, recording inaccurate weights for at least eight consecutive weekly entries. This led to the facility not recognizing or intervening in the resident's substantial weight loss, which was eventually discovered to be 25.5 pounds. The resident's designated power of attorney repeatedly raised concerns about the resident's declining condition and appearance, but the facility assured them that no weight loss had occurred, based on the falsified records. Interviews and record reviews confirmed that the CNA responsible for obtaining and documenting weights did not consistently perform the task and instead entered false data. The CNA's skills checklist for measuring and recording weight was left incomplete, and the DON confirmed through video review that weights were not being properly obtained. The resident was observed to appear thin and expressed a lack of appetite. The facility's own policy defines neglect as the failure to provide necessary goods and services to avoid harm, and the investigation concluded that both abuse and neglect had occurred in this case.