Failure to Monitor Resident Weight as Required by Policy
Penalty
Summary
The facility failed to ensure ongoing monitoring of a resident's weight status, as required by its own policy and standard clinical practice. The policy specified that residents should be weighed weekly for the first four weeks after admission and then monthly unless otherwise indicated, with all weights documented in the medical record. A resident with progressive Multiple Sclerosis was admitted and initially weighed according to policy, but after the last recorded weight, no further weights were obtained for over three months. There was also no evidence of a current physician's order to continue monthly weight monitoring, and this lapse was not identified by facility staff. Interviews with the Nurse Practitioner and the Director of Nursing Services confirmed that they were unaware of the missed weight checks and acknowledged the failure to monitor the resident's weight as required. When a weight was finally obtained after the surveyor's inquiry, it was found that the resident had gained 24.3 pounds since the last recorded weight. This significant weight gain went undetected due to the lack of ongoing monitoring, contrary to facility policy and expectations.