Failure to Follow Physician Orders for Weight Monitoring and PRN Medication
Penalty
Summary
The facility failed to follow physician orders and the resident's care plan for a resident with diagnoses including congestive heart failure, atrial fibrillation, and hyperlipidemia. The resident had specific physician orders for daily weights, with instructions to notify the physician and administer PRN Lasix if the resident experienced a weight gain of 2 pounds in one day or 5 pounds in one week. The care plan also included interventions to obtain weights as indicated and report significant changes. On two separate occasions, the resident experienced weight gains that met the criteria for physician notification and PRN Lasix administration: a 2.8-pound gain in one day and a 4.6-pound gain in one day. However, there was no documentation that the physician was notified or that the PRN Lasix was administered as ordered. The DON confirmed during interview that these actions were not taken, despite expectations that staff would follow the physician's orders and care plan.