Failure to Administer Lasix and Monitor Weight in Resident with CHF
Penalty
Summary
The facility failed to prevent a significant medication error for a resident with a primary diagnosis of acute on chronic systolic congestive heart failure. Upon admission, the resident was prescribed Lasix, a diuretic medication, to manage their condition. However, the medication was not administered until two days after admission, despite the last dose being given three days prior. There was no documentation explaining the omission of the Lasix doses, nor was there any record of the physician being notified for further directives. Additionally, the facility did not adhere to the physician's orders for daily weight monitoring, which is crucial for managing congestive heart failure. The resident's weight was not recorded on several days, and there was a discrepancy between the physician's plan of care and the facility's implementation of weekly weight orders. This lack of consistent weight monitoring led to a failure in identifying the resident's weight gain, which was a critical indicator of their health status. The resident's wife expressed concerns about the care provided, particularly regarding the administration of Lasix and the monitoring of the resident's condition. Despite the physician's notes indicating the need for daily weights and adjustments in Lasix dosage, these were not consistently followed, and there was no notification to the cardiologist as instructed by the transferring hospital. The facility's oversight in medication administration and weight monitoring contributed to the significant medication error and inadequate management of the resident's congestive heart failure.