Failure to Consistently Obtain and Document Daily Weights per Physician Order
Penalty
Summary
The facility failed to consistently follow a physician's order for obtaining daily weights for a resident with multiple complex medical conditions, including congestive heart failure, diabetes mellitus, obesity, repeated falls, hypertension, chronic obstructive pulmonary disease, edema, and dementia. The resident's care plan specifically required daily weights due to diuretic therapy and the potential for weight fluctuations, with instructions to notify the physician if certain weight gains occurred. Despite these orders, review of the resident's Treatment Administration Record (TAR) revealed numerous dates where weights were not documented, and there was a lack of consistent documentation regarding refusals of daily weights. Interviews with staff indicated that CNAs were responsible for obtaining daily weights and were to notify the nurse if unable to do so, while nurses were responsible for ensuring weights were obtained or refusals documented. However, the EMR showed multiple missed entries for daily weights and lacked consistent documentation of refusals. The facility's policy required maintaining a schedule of diagnostic tests and a reliable process for providing physician-ordered services, but this was not consistently followed for the resident in question.