Failure to Complete and Communicate Daily Weights for CHF Resident
Penalty
Summary
The facility failed to ensure that daily weights were completed as ordered for a resident with congestive heart failure (CHF), and did not identify or communicate significant weight increases to the physician. The resident, who had severe cognitive impairment and multiple comorbidities including CHF, COPD, and respiratory failure, was admitted with explicit hospital discharge instructions for daily weight monitoring and prompt reporting of weight gains. Despite these orders, daily weights were inconsistently documented, and significant weight changes were not communicated to the physician as required. Review of the electronic medical record and eMAR revealed multiple gaps in weight documentation, including days when weights were not recorded and periods when incorrect orders were entered, resulting in missed daily weights. On several occasions, the resident experienced notable weight gains that met the threshold for physician notification, but there was no evidence that the physician was informed. The care plan for CHF did not include specific interventions for daily weights or physician notification of weight changes, and the facility lacked a policy addressing CHF care or daily weight monitoring. Interviews with staff and the resident's physician confirmed concerns about the lack of consistent daily weight monitoring and communication. The physician reported receiving weight updates only once and expressed frustration with the lack of follow-through on orders. The DON acknowledged the importance of daily weights for CHF management and expected staff to complete them as ordered, but also confirmed the absence of a facility policy specific to CHF or daily weights. These failures resulted in the resident being transferred to the hospital multiple times for CHF exacerbations.