Failure to Monitor and Report Ongoing Weight Loss and Obtain Ordered Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and respond to a resident’s weight loss and to follow its own policy for obtaining weekly weights after admission. The resident had been hospitalized for a subdural hematoma and underwent a craniotomy before being admitted to the facility for rehabilitation. The admission care plan identified the resident as being at risk for weight loss with a goal to maintain current weight. A physician’s order directed that the resident be weighed weekly, every Tuesday, and the facility’s policy required weekly weights for the first four weeks after admission. The weight records showed documented weights of 179 lbs on admission, 170.4 lbs one week later, and 167.4 lbs two weeks after that, but no weight was documented on the intervening Tuesday, and there was no documentation that the resident refused to be weighed. The records showed a 6.5% weight loss from admission to the later date. The dietitian assessed the resident shortly after admission and again after the initial significant weight loss, attributing the early loss to fluid shifts and resolving edema from hospitalization and IV fluids, and directed staff to continue monitoring weights and to notify her of any continued weight loss. Despite further documented weight loss between the second and third recorded weights, there was no evidence that staff notified the dietitian of this continued decline. During interview and record review, the dietitian confirmed that the resident should have been weighed weekly, that she had not been informed of the ongoing weight loss, and that she would have reassessed the resident if notified. The resident, who was alert and cognitively intact, reported having lost a lot of weight since surgery, described a decreased appetite after surgery that had only recently begun to improve, and stated he had been weighed a couple of times in the facility and had not refused to be weighed.
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