Failure to Follow Physician Orders for Weights and IV Labeling
Penalty
Summary
The facility failed to follow physician orders and care plans for two residents regarding weight monitoring and intravenous (IV) medication administration. For one resident with severe cognitive impairment, the care plan required weekly weights every Wednesday as ordered by the physician. However, electronic health records showed inconsistent documentation, including missed weights, incorrect entries, and a lack of follow-up when weights were recorded as incorrect. Staff interviews confirmed that weights were typically done monthly unless otherwise directed, and that incorrect weights should have been rechecked by the next day, which was not consistently done. For another resident with moderate cognitive impairment receiving IV antibiotics via a PICC line, physician orders and the care plan required that IV bags and tubing be labeled with the date, time, and nurse's initials, and that administration sets be changed every 24 hours. Observations on multiple occasions found empty IV bags and tubing hanging without the required labeling. Staff confirmed that labeling was expected per orders, but the required information was not present on the used IV sets and bags.