Failure to Obtain and Document Monthly Weights as Ordered
Penalty
Summary
The facility failed to follow physician orders for obtaining monthly weights for a resident diagnosed with Parkinson's disease, dementia, and major depressive disorder. The physician had ordered monthly weights to be taken within the first week of each month for monitoring purposes. However, the medical record lacked documented weights for three consecutive months, specifically September, October, and November. This omission was identified through record review and confirmed by staff interviews, which revealed that Certified Nurse Assistants (CNAs) had not consistently obtained the required monthly weights. Multiple staff members, including the DON, Unit Manager, ADON, and Registered Dietitian, acknowledged ongoing challenges in obtaining accurate and consistent weight measurements. They indicated that missing or inaccurate weights had negatively impacted care planning and delayed timely interventions for residents experiencing weight loss or significant changes. The facility's policy required nursing staff to measure resident weights as ordered by the physician, but this was not consistently followed for the resident in question.