Failure to Monitor Weights and Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to monitor weights as ordered for a resident with significant weight loss and multiple complex medical conditions. The resident, an eighty-three-year-old female with diagnoses including Parkinson's disease, acute post hemorrhagic anemia, stage 3 sacral pressure ulcer, dysphagia, mild protein-calorie malnutrition, and pancreatic cancer, was readmitted from the hospital with a physician's order for weekly weights. Despite this order, only two weights were documented in the medical record over a period of more than a month, and the clinical nutrition manager confirmed that regular weight monitoring is necessary to identify and address weight loss. Additionally, the facility failed to apply compression stockings as ordered for a resident with a history of blood clots. The resident, who had a right lower extremity deep vein thrombosis and an inferior vena cava filter, had a physician's order for bilateral knee-high stockings to be applied in the morning and removed at bedtime. Observations on multiple occasions showed the resident was not wearing the stockings, and an LPN was unsure if the resident was supposed to wear them. The director of nursing confirmed that the expectation is to follow all physician orders, including those for compression stockings.