Failure to Notify Physician of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the physician when a resident with a diagnosis of congestive heart failure (CHF) and on a diuretic experienced significant weight gains within 24-hour periods. The resident's care plan and physician orders required daily weight monitoring due to the use of a diuretic, and the facility's records showed multiple instances where the resident gained between four and seven pounds in a single day. Despite these notable weight increases, there was no documentation that the physician was notified on any of these occasions. Interviews with nursing staff revealed that the expectation was for the nurse on duty to notify the physician of significant weight changes, particularly if there was a three-pound or greater gain in a day, even if specific parameters were not outlined in the physician's order. However, the facility did not have a policy in place regarding provider notification for weight changes in residents with CHF on diuretics. Observations of the resident showed swelling in the legs and episodes of shortness of breath, but there was no evidence that these changes prompted physician notification as required.