Failure to Complete Ordered Weights and Document Assessment Prior to ER Transfer
Penalty
Summary
The facility failed to ensure that a resident with multiple chronic conditions, including congestive heart failure, chronic obstructive pulmonary disease, morbid obesity, obstructive sleep apnea, hypertension, and chronic kidney disease, received care and treatment according to physician orders and care plan interventions. Specifically, the resident had provider orders for daily weights and fluid restriction, as well as multiple diuretic medications. However, the electronic medical record for April did not show that weights were taken as ordered, with only three weights documented for the entire month. There was no documentation of the resident refusing weights or any progress notes explaining missed weights. Additionally, prior to the resident being sent to the emergency department for leg pain and edema, there was no assessment or documentation in the medical record regarding the resident's symptoms or the decision to transfer. Observations noted the resident had significant lower extremity edema and pain, and interviews with staff confirmed that documentation and assessment were expected but not completed. The director of nursing and registered nurse both acknowledged that daily weights and documentation of refusals or assessments prior to ER transfer should have occurred.