Failure to Notify Practitioner of Significant Weight Gain in Residents with Heart Failure
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents diagnosed with congestive heart failure. Both residents had physician orders and hospital discharge instructions requiring daily weights and prompt notification to the practitioner if there was a weight gain of 2-3 pounds overnight or 5 pounds in one week. For one resident, the clinical record showed a weight gain of 3.2 pounds overnight, and for the other, a weight gain of 3.1 pounds overnight. In both cases, there was no evidence in the clinical records that the practitioner was notified of these significant weight changes as required by the orders. Interviews with the Director of Nursing confirmed that there was no documentation or evidence of practitioner notification regarding the residents' overnight weight gains. The failure to notify the practitioner as ordered resulted in the facility not following the prescribed care plan for residents with heart failure, as required by professional standards and facility policy.