Failure to Document Ordered Weekly Weights for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records by not documenting physician‑ordered weekly weights for one resident. The resident was an elderly female with multiple diagnoses including hemiplegia/hemiparesis, vascular dementia, muscle wasting and atrophy, chronic kidney disease stage 2, and a Stage 3 pressure injury present on admission. Her admission MDS showed moderate cognitive impairment with a BIMS score of 11, and she was identified as being at risk for developing pressure ulcers. Her care plan identified a potential for nutritional problems related to chronic kidney disease, lung cancer, and a history of pneumonitis, with interventions that included monitoring, recording, and reporting signs and symptoms of malnutrition and significant weight loss. Record review showed that a physician order dated 03/12/26 directed that the resident be weighed weekly for four weeks on the day shift every Thursday for weight monitoring. Review of the resident’s electronic chart, including the March MAR/TAR and vitals tab, revealed that no weights were documented from the time the order was given on 03/12/26 through 03/31/26. Review of nursing progress notes for the same period showed no recorded weights and no documentation of refusals to be weighed. This lack of documentation occurred despite the facility’s policy requiring nursing staff to monitor and document resident weights in a format that permits comparison over time and to report significant weight changes to the physician and dietitian. Interviews with staff confirmed that weights were expected to be recorded and that weekly weights were required for new admissions and readmissions for the first four weeks. LVN A stated that weights should be recorded on the MAR/TAR and that she relied on the treatment nurse and CNAs to complete them, while also stating she was not responsible for verifying whether weights were taken or accurate. The DON stated that weights should be documented under the vitals tab and that refusals required a progress note. The treatment nurse (LVN B), identified as the weight loss monitoring nurse, reported she was responsible for monitoring resident weights, that some residents had weekly weights triggered in the e‑chart, and that she sometimes delegated weights to CNAs due to workload. The ADON stated that if weekly weights after admission were not completed, she would expect a nursing note explaining why, but no such notes were found for this resident, confirming the incomplete and inaccurate medical record.
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