Failure to Follow Physician's Order for Weight Monitoring
Penalty
Summary
A deficiency occurred when facility staff failed to follow a physician's order for scheduled weight monitoring for a resident with diagnoses including cognitive communication deficit, hypotension, edema, muscle weakness, and unsteady gait. The resident's care plan required nursing staff to administer medications as ordered and observe for adverse effects, with specific physician orders for diuretic medications and to obtain weights every Monday and Thursday to monitor for fluid overload. Review of the resident's electronic medical record, medication administration record, and treatment administration record over a specified period showed that weights were not obtained as ordered, and there was no evidence that the physician was notified of the missed weight monitoring. Observations confirmed the resident's ongoing medical needs, and interviews with administrative nursing staff indicated an expectation that physician orders, including weight monitoring, should be followed and that the physician should be notified if orders are not carried out. The facility's policy required accurate implementation of all orders, but documentation and practice did not reflect compliance with the weight monitoring order for this resident.