Failure to Obtain Weekly Weights as Ordered for Resident with CHF
Penalty
Summary
The facility failed to follow physician orders for obtaining weekly weights for a resident with multiple complex medical conditions, including congestive heart failure. The physician's order specified that the resident's weight should be checked weekly and that the physician should be notified if there was a weight gain of five pounds in one week. However, medical record review showed that weights were not consistently documented on a weekly basis, with significant gaps between recorded weights. The resident involved had diagnoses such as multiple sclerosis, diabetes, atrial fibrillation, morbid obesity, chronic kidney disease, and lymphedema, and was dependent on staff for several activities of daily living. Despite facility policy requiring weekly weights when ordered, the documentation revealed that this was not done as directed. The DON confirmed during interview that weekly weights had not been obtained according to the physician's orders.