Failure to Document and Respond to Significant Weight Changes in Resident with CHF
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with congestive heart failure and atrial fibrillation. Physician orders required daily weights and notification of the practitioner if the resident gained 2 pounds or more in a day or 5 pounds in a week. Documentation showed that daily weights, or refusals, were not recorded for multiple days across three months. Additionally, a significant weight gain of 11.7 pounds in one day was documented, but there was no evidence that the practitioner was notified or that a reweigh was performed. The Director of Nursing confirmed that daily weights should have been recorded and appropriate follow-up should have occurred when the weight gain was identified.