Failure to Follow Physician Orders for Weight Monitoring in Heart Failure Patient
Penalty
Summary
The facility failed to follow physician orders for obtaining weights for a resident with a history of hypertensive heart disease, heart failure, and documented weight loss. The resident's care plan identified the need for close monitoring due to the use of diuretic medications, which can cause weight fluctuations. The physician order specified that the resident's weight should be obtained every morning, with instructions to notify the physician if there was a weight gain of 2 pounds in one day or 5 pounds in one week. However, the order also included a frequency of once daily every Tuesday and Thursday, leading to confusion among staff. A review of the resident's weight records for May showed that weights were only documented on two occasions, with a 16-day gap between entries. The Assistant Director of Nursing confirmed that weights were not obtained as ordered and acknowledged the importance of daily weights for monitoring heart failure exacerbations. The facility's policy required weights to be recorded in both the unit's weight record chart and the resident's medical record, but this was not consistently done for the resident in question.