Failure to Follow Physician Orders and Monitor Significant Weight Changes
Penalty
Summary
The facility failed to follow physician orders and adequately monitor significant weight changes for three residents reviewed for nutrition. For one resident with diagnoses including congestive heart failure and chronic kidney disease, daily weights were ordered with instructions to subtract the wheelchair weight. However, a significant weight gain of over 40 pounds was recorded within four days due to failure to subtract the wheelchair weight, as confirmed by the dietitian and staff interviews. The Director of Nursing was unable to provide a valid explanation for this discrepancy, and the resident's weight was not appropriately monitored or addressed. Another resident with progressive bulbar palsy, severe protein calorie malnutrition, ALS, and other complex conditions was ordered to have weekly weights for four weeks. The clinical record showed that the resident was not weighed on one of the scheduled dates, and there was no documented explanation for the missed weight. The dietitian confirmed that nursing staff were responsible for obtaining weights and that the missed weight was reported to the nursing supervisor the following day, but the physician's orders for weekly weights were not followed. A third resident with dementia, anxiety disorder, muscle weakness, and depression was also ordered to have weekly weights. The clinical record revealed a significant weight loss of 12.2 pounds between two documented weights, and there was no evidence that a weight was obtained on one of the scheduled dates as ordered. These findings demonstrate that the facility did not ensure physician orders for weights were followed and failed to adequately monitor and address significant weight changes for these residents.