Failure to Verify Significant Weight Gain and Notify Dietitian
Penalty
Summary
The facility failed to ensure the accuracy of a resident's weight measurement and did not communicate a significant weight gain to the Registered Dietitian for further nutritional assessment. A resident with multiple diagnoses, including right above the knee amputation, atrial fibrillation, hypertension, congestive heart failure, and peripheral vascular disease, experienced a weight increase of 26.8 pounds over 19 days. The care plan for this resident included monitoring for fluid volume excess and required staff to alert the dietitian and physician to any significant weight changes. Despite the electronic medical record flagging the weight gain as significant, staff did not perform a reweight within 24 hours as required by facility policy, nor did they review previous weights before entering the new value. Interviews with the Unit Manager, Nurse Practitioner, and Registered Dietitian confirmed that a reweight should have been conducted promptly for any weight change exceeding 5% in a month or 10% in six months. The Registered Dietitian was not notified of the significant weight gain until informed by the surveyor, and no additional weights were documented after the initial flagged entry. The Director of Nursing also confirmed that the expectation was for nursing staff to perform a reweight within 24 hours in the event of such discrepancies, which did not occur in this case.