Failure to Monitor Resident Weights per Facility Policy
Penalty
Summary
The facility failed to obtain and monitor a resident’s weights in accordance with its Weight Management policy, which required all residents to be weighed on admission, weekly for four weeks, and then monthly or as indicated by the physician. One resident with diagnoses including Alzheimer’s disease, an unstageable sacral pressure ulcer, metabolic encephalopathy, congestive heart failure, and essential tremor was admitted with impaired cognition, required moderate assistance with eating, and was dependent on staff for toileting hygiene, bed mobility, and transfers. Record review showed this resident was weighed on admission at 164 lbs and then on two subsequent occasions at 165.2 lbs and 164.2 lbs, with no further weights documented before the resident was hospitalized and did not return. In an interview, the unit manager confirmed the facility’s weight-monitoring expectations and verified that no additional weights were obtained or recorded for this resident beyond the three documented weights, despite the resident remaining in the facility until hospital transfer. This deficiency was cited as non-compliance with the facility’s weight management policy under Complaint Number 2709811.
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