Inaccurate Documentation of Resident Body Weight
Penalty
Summary
The facility failed to accurately document a resident’s body weight in the medical record. The resident was originally admitted with diagnoses including Parkinson’s disease, dysphagia, dementia, bipolar disorder, and hypotension, and had intact cognition and independence with ADLs per the MDS. A weight summary for the resident from early January to early March showed weights of 159 lbs on two occasions and 158 lbs on a later date. However, a separate list of resident weights obtained by a restorative nursing attendant on February 28 documented the resident’s weight as 148 lbs. On March 5, another restorative nursing attendant weighed the resident and obtained a weight of 143 lbs. During a subsequent review and interview, the ADON confirmed that the weight summary entry of 158 lbs on March 3 had been entered by the ADON and was incorrect, and that the resident’s weight should have been documented as 148 lbs based on the February 28 measurement. The DON also stated that the resident’s body weight should have been accurately documented in the medical record to reflect the correct weight of 148 lbs. This inaccurate documentation was inconsistent with the facility’s charting and documentation policy, which requires that medical records be objective, complete, and accurate and facilitate communication about the resident’s condition and response to care.
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