Failure to Follow Physician's Order for Daily Weights in Resident with CHF
Penalty
Summary
The facility failed to follow a physician's order for daily weights for a resident with multiple diagnoses, including congestive heart failure (CHF), diabetes mellitus, peripheral vascular disease, kidney disease, and edema. The resident's care plan required daily weights before breakfast, with instructions to notify the physician if there was a weight gain of more than two pounds in one day or five pounds in one week. Despite these orders, review of the resident's electronic medical record, medication administration record, and treatment administration record revealed that staff did not measure and record the resident's weight on nine specific dates over a 69-day period. There was also no documentation that the physician was notified when the daily weights were not obtained. Interviews with staff confirmed that all staff were responsible for assisting with daily weights if ordered, and that the nurse was responsible for ensuring weights were obtained, recorded, and that the physician was notified as needed. The facility's policy required all medications and treatments to be administered as ordered by a healthcare professional. However, the lack of documentation and failure to follow the physician's order for daily weights constituted a deficiency in providing appropriate treatment and care according to orders, resident preferences, and goals.