Failure to Follow Dialysis Orders for Daily Weights
Penalty
Summary
The facility failed to follow dialysis recommendations for daily weights for a resident with End Stage Renal Disease, dependence on renal dialysis, and dementia. Documentation shows that the dialysis provider requested a 1200 cc fluid restriction and daily weights for the resident, and this order was added to the active physician orders. However, the resident's records indicate that after being weighed on 5/24/25, no additional daily weights were recorded. Staff interviews confirmed that the resident did not refuse to be weighed and that the dialysis provider had specifically requested daily weights due to concerns about weight gain and fluid overload. The Director of Nursing acknowledged that there were issues with new scales and with weights not transferring from the MAR to the Weight Summary report, and verified that the daily weight order was not carried over to the MAR for completion.