Failure to Obtain Ordered Weekly Weights and Address Significant Weight Gain
Penalty
Summary
The deficiency involves the facility’s failure to obtain and monitor a newly admitted resident’s weekly weights as ordered and to address a significant weight gain. The resident, who was cognitively intact and diagnosed with heart failure, hypertension, and morbid obesity, was 5'3" and weighed 365 lbs on admission. The physician ordered weekly weights on Sundays beginning 03/01/2026. The EMAR showed the resident was weighed at 365 lbs on 03/01/2026, not weighed on 03/08/2026, and then weighed at 389 lbs on 03/15/2026 and 393 lbs on 03/22/2026, reflecting a 24 lb gain between 03/01/2026 and 03/15/2026. The DON stated that newly admitted residents were to be reviewed weekly in SWAT meetings for at least four weeks and that the resident’s weight should have been obtained weekly and the significant weight gain addressed, but the DON was unaware of the 24 lb gain. SWAT assessments documented on 03/06/2026 and 03/14/2026 indicated the resident was on weekly weights. The 03/06/2026 SWAT note stated the resident’s weight was up 5 lbs since admission and to monitor for further changes, and the 03/14/2026 SWAT note indicated the resident needed an updated weekly weight. The EHR contained no further SWAT assessments and no documentation that the resident refused to be weighed. Laboratory tests from 02/25/2026 showed high cholesterol and triglycerides and low red blood cells, hemoglobin, and hematocrit, and the resident was not receiving nutritional supplementation. Facility policy on obtaining residents’ weights required comparison of weights to prior values, reweighing for significant variances (e.g., 5 lbs more or less), correction and notation of incorrect weights, and adherence to weekly weight orders, while the SWAT policy required weekly monitoring of new admissions and residents with significant weight changes. These policies were not followed for this resident’s ordered weekly weights and significant weight gain.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.