A Registered Dietitian performed a quarterly visit at a long-term care community and identified that for the past three months the weights and pressure injuries had not been recorded for the residents. It is essential to adhere to resident care plans by consistently identifying these measurements in order to intervene on significant and insidious weight changes and pressure injuries. Failure to chart these measurements could be flagged as an inadequate quality of care with regard to nutrition maintenance.
In response, the Registered Dietitian retrieved the most recent Certification and Survey Provider Enhancement Reports (CASPER) which identifies the residents that have had significant weight changes. They then partnered with the Director of Nursing to obtain and record the weight of each resident in their medical record. Fortunately, no clinical issues were identified. A Quarterly Audit was implemented to ensure that these statistics would be gathered on a regular basis.