Failure to Obtain and Document Daily Weights for Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document daily weights for a resident with Congestive Heart Failure (CHF) as ordered by the physician. The resident, who had a history of hypertension, CHF, and diabetes, was admitted in July 2024 and had a care plan that included daily weight monitoring due to the risk of fluid overload associated with CHF. Despite a physician's order to weigh the resident every day and notify the physician of significant weight changes, the clinical record showed that weights were only recorded sporadically over several months, with significant gaps in documentation. There was no evidence in the record of the resident refusing to be weighed, nor were refusals or reasons for missed weights documented. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the daily weight order was current and should have been followed, and that any refusals should have been documented. However, staff were unable to explain why the resident was not weighed as directed. Additionally, the facility's weight policy required documentation of refusals or circumstances preventing weighing, but this was not done. The facility was unable to provide a specific CHF policy when requested.