Inaccurate Weight Documentation in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate clinical record documentation for a resident’s weight, as required by its nutritional assessment policy and professional standards. The facility’s policy from 2001 states that the physician, dietitian, and nursing staff share responsibility for nutritional assessment and care, and that a nutritional assessment is required when a resident experiences a change in condition. The policy further specifies that the interdisciplinary team must use data gathered throughout the resident’s stay, including usual intake, appetite, meal and snack patterns, preferred portion sizes, and current clinical conditions affecting nutritional status, and that the dietitian is responsible for assessing and monitoring nutritional intake and identifying increased caloric and protein needs. For one resident, a quarterly MDS assessment documented a height of 66 inches and a weight of 215 pounds. However, a dietitian’s progress note dated December 31, 2025, recorded the resident’s weight as 122 pounds, in contrast to the 215.8 pounds documented by nursing staff on the same date. In an interview, the DON confirmed that the correct weight recorded by nursing staff on December 31, 2025, was 122 pounds, and also confirmed a weight of 122 pounds recorded by nursing staff on February 26, 2026. These discrepancies show that the resident’s clinical record did not accurately reflect the resident’s actual weight, constituting a failure to maintain accurate medical records in accordance with accepted professional standards and the facility’s own policies.
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