Failure to Obtain Accurate Weights Resulting in Undetected Severe Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to obtain accurate weights and complete accurate nutritional assessments for one resident, resulting in a significant, previously unrecognized weight loss. The resident, who was cognitively intact, quadriplegic, and dependent on staff for all ADLs, was observed on multiple occasions to appear very thin, with visible ribs and thin arms and legs while lying in bed. Review of the clinical record showed a series of monthly weights from July through early January consistently documented around 148–149 lbs using a Hoyer lift. A weight of 121.6 lbs recorded in December was crossed out by an LPN with the notation “Incorrect Documentation,” and subsequent documentation again reflected a weight in the 149 lb range. When asked, the resident reported being weighed only occasionally and estimated his own weight at about 132 lbs, with a height of 6 feet 1 inch. On direct observation of staff weighing the resident with a mechanical lift, the resident’s actual weight was found to be 120.0 lbs, which was 29.6 lbs less than the most recently documented weight of 149.6 lbs recorded five days earlier. The RD reported that the resident’s weights had not triggered concern because they appeared stable in the record and stated she was in the process of working on the resident’s nutrition evaluation. After being informed of the observed 120.0 lb weight, the RD acknowledged that the resident did not look like he would weigh 149.6 lbs. The DON stated that CNAs obtained resident weights and entered them into the chart but did not provide an explanation for the large discrepancy between the documented and observed weights before the end of the survey. When surveyors requested a facility policy on weight management and obtaining accurate weights, no policy was provided prior to the end of the survey.
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