Failure to Monitor and Document Ordered Weights for Multiple Residents
Penalty
Summary
The facility failed to monitor and document resident weights according to physician orders and its own "Weight Protocol" policy, which required weights within 24 hours of admission, weekly for four weeks, and then monthly. One resident admitted in early February with COPD and a communication deficit had a care plan to monitor weights per facility policy and a physician order for weekly weights for four weeks then monthly; however, there was no recorded weight from 2/11 through discharge to the hospital on 2/14, and after readmission and a new order for weekly weights, no weights were documented after 3/3 for March and April, with no refusals noted. Another resident admitted in late March with heart failure and diabetes had a care plan to monitor weights per policy and a physician order for weekly weights for four weeks then monthly, but there were no documented weights after the admission date. A third resident admitted in early February with heart failure and diabetes had a care plan and physician order for weekly then monthly weights, yet only two weights were recorded in early March, and a subsequent weight obtained at surveyor request in April showed a 51‑pound change over 36 days, with no intervening weights documented. A fourth resident admitted in mid‑January with heart failure and kidney disease had a care plan and physician order for weekly then monthly weights, but no weights were recorded after 2/1 for February through April, until a weight was obtained at surveyor request in April showing an approximate 15‑pound change over two months. The Nursing Home Administrator confirmed that the facility failed to properly monitor weights as ordered for four of six reviewed residents.
Plan Of Correction
Residents R15 has discharged from the facility, Residents R18, R29 and R33 will have their weights reviewed by the Dietitian for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care changes. Resident weights will be completed on admission, weekly times 4 and then monthly until a physician order changes this policy. Weights will be reviewed by the Dietitian and DON/Designee. The Dietitian will review for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care changes. Education will be provided by the DON/designee to the nursing staff that resident weight needed to be completed upon admission, then weekly times four and monthly by the 7 th of the month per the weight policy. DON/Designee will complete audits for weights recorded at 90% of resident admissions, weekly weights, and monthly weights and ensure the Dietitian has reviewed the weights for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care adjustments. Results of these audits will be reviewed at the QAPI committee meeting for further recommendations
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