Failure to Obtain Accurate Weights Delays Nutritional Intervention
Penalty
Summary
The facility failed to obtain accurate and consistent weights for a resident with dementia, dysphagia, and a history of cerebral infarction, as required by physician orders. The resident was to be weighed on admission, then weekly for four weeks, and subsequently every Thursday for routine monitoring. However, the weight log showed missing and inaccurate entries, including a documented error that was not followed by a re-weigh, and a missed weight on a scheduled date. There was also no physician order for a re-weigh after an inaccurate weight was recorded. These inconsistencies in weight documentation led to a delay in identifying significant weight loss. Interviews with facility staff, including the Nutritional Services Director, Assistant Director of Nursing, Director of Nursing, and Registered Dietician, confirmed ongoing issues with obtaining timely and accurate weights, as well as challenges in getting re-weighs completed. The resident was noted to have refused meals and required assistance with eating, but meal intake documentation was found to be unreliable. The delay in obtaining accurate weights contributed to a delay in providing a nutritional supplement, which was only ordered after a significant weight loss was finally documented.