Failure to Follow Physician Orders for Weight Monitoring and Medication Administration
Penalty
Summary
The facility failed to follow physician orders and its own policies regarding the monitoring and documentation of residents' weights and medication administration. For one resident with congestive heart failure (CHF), daily weight monitoring was ordered by the physician but was not performed on multiple specified dates. The Assistant Director of Nursing (ADON) confirmed that the required daily weights were not taken and could not provide an explanation for the missed monitoring. Another resident with CHF also had a physician's order for daily weight monitoring, which was not completed on several dates. Additionally, this resident experienced a six-pound weight gain over four days, but there was no documentation that the physician was notified as required by facility policy. The ADON confirmed both the missed weight checks and the lack of physician notification regarding the significant weight gain. A third resident with orthostatic hypotension had a physician's order for Midodrine to be administered only if the systolic blood pressure (SBP) was below 120 mmHg. The medication administration record showed that the medication was given multiple times without checking blood pressure parameters and, on several occasions, was administered outside the ordered parameters. The Interim Director of Nursing confirmed that the medication parameters were not followed. These findings demonstrate that the facility did not ensure physician orders were consistently followed for weight monitoring and medication administration for the residents reviewed.