Failure to Notify Provider of Significant Weight Gain in CHF Resident
Penalty
Summary
Staff failed to notify the provider of a significant weight gain in a resident with a history of Congestive Heart Failure (CHF), coronary artery disease, and pulmonary hypertension. The resident was on a diuretic medication and had physician orders for weekly weights. The resident's weight increased by 27.2 pounds in one week, but there was no documentation that the physician or provider was notified of this change. Nursing staff observed the weight gain but did not report it, citing the absence of a specific physician order requiring notification for significant weight changes. Interviews with the Director of Nursing, Physician Assistant, and Medical Director confirmed that their expectation was for the provider to be notified of weight gains greater than 5 pounds, especially for residents with CHF. Both the PA and MD stated they were not made aware of the weight gain and would have expected to be notified to assess and potentially adjust treatment. The deficiency was identified for one resident reviewed for notification of change.