Failure to Notify Provider of Significant Weight Gains in Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to monitor and report significant weight fluctuations for a resident with a diagnosis of congestive heart failure (CHF). The resident's care plan required daily weights and provider notification for weight gains of three pounds overnight or five pounds in three days, as well as for increased shortness of breath or swelling. Despite this, the electronic medical record showed multiple instances where the resident experienced weight gains meeting or exceeding these thresholds, but there was no documentation that the provider was notified as required by the care plan. Observations confirmed the resident had edema in both legs and was wearing compression socks. Interviews with nursing staff revealed awareness of the notification requirement, and administrative staff stated the expectation that orders be followed. However, no policy was provided to support the process, and the required notifications to the provider were not made on several occasions when the resident's weight increased significantly.