Failure to Obtain Daily Weights and Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to obtain daily weights as ordered and did not notify the physician of significant weight changes for two residents with congestive heart failure and other complex medical conditions. For one resident, daily weights were ordered with specific parameters for physician notification in the event of a weight gain of 2 pounds or more in one day or a change of 5 pounds in one week. The resident was not weighed on two separate days, and there was no documentation that the physician was notified of the missed weights, despite the resident and her daughter expressing concerns about increased swelling and weight gain. The Executive Director confirmed that a new daily weight order was not properly saved in the system, resulting in a missed weight, and the reason for another missed weight was unknown. For the second resident, daily weights were also ordered with similar notification parameters. The clinical record showed multiple instances where the resident's weight increased by more than 2 pounds in one day, but there was no documentation that the physician was notified of these changes. Staff interviews confirmed that daily weights were to be obtained and recorded in the Medication Administration Record, and that staff were responsible for ensuring completion and documentation. The facility's policy required daily weights as ordered and a multidisciplinary approach to weight monitoring, but this was not followed for the residents reviewed.