Failure to Follow Physician Orders for Medication and Weight Monitoring
Penalty
Summary
Facility staff failed to follow physician's orders for a resident with complex medical conditions, including heart disease, heart failure, and high blood pressure. The physician's orders required daily weight monitoring with notification to the physician if the resident gained more than two pounds in a day or five pounds in a week. On one occasion, the resident's weight increased by 4.2 pounds in a single day, but there was no documentation that the physician was notified as required by the order. The facility's policy also required monitoring for undesirable weight changes, which was not followed in this instance. Additionally, the resident had an order for a blood pressure medication that was to be held if their pulse was less than 60 beats per minute. Despite the resident's pulse being recorded at 57 beats per minute on one occasion, the nurse administered the medication instead of holding it as directed. The Resident Care Manager confirmed that the physician was not notified of the weight gain and that the medication should have been held when the resident's pulse was below the specified threshold.