Failure to Implement Physician Orders for CHF Residents
Penalty
Summary
The facility failed to implement physician's orders for daily weight monitoring and medication administration for two residents with congestive heart failure (CHF). Resident #17, a female with acute on chronic combined systolic and diastolic CHF, had orders for daily weights and to report significant weight changes to her physician. However, weights were not recorded on several specified dates, and there was no documentation that the provider was notified of weight increases exceeding 2-3 pounds in one day, which could indicate worsening heart failure. Similarly, Resident #89, a male with chronic combined systolic and diastolic CHF, had orders for daily weights and as-needed Lasix for weight gain. Weights were not obtained on several dates, and the as-needed Lasix was not administered despite significant weight increases. The Director of Nursing (DON) confirmed that the weights were not obtained daily for both residents and acknowledged that licensed nurses were responsible for ensuring daily weights and monitoring weight trends. The DON identified that the inconsistency in obtaining weights was due to nursing staff assuming that certified nursing assistants had completed the task without verification. The facility lacked a specific policy or procedure for managing residents with CHF, contributing to the oversight in care. The report highlights the importance of accurate weight monitoring as an indicator of fluid status and the need for adherence to physician orders to manage CHF effectively.