Failure to Follow Physician's Orders for Weight Monitoring in CHF Patient
Penalty
Summary
The facility failed to follow a physician's order for daily and weekly weights for a resident diagnosed with congestive heart failure (CHF), among other conditions. The resident's electronic medical record (EMR) included orders for daily weights for three consecutive days and weekly weights thereafter, which were not documented as completed on the specified dates. The July Medication Administration Record (MAR), Treatment Administration Record (TAR), and Weights/Vital Signs tab lacked evidence of daily weights for three days and weekly weights for two separate weeks. Interviews with staff confirmed that the process for obtaining and documenting weights involved communication between CNAs and nurses, with the charge nurse responsible for ensuring orders were followed and weights were recorded in the EMR. The resident had a history of CHF, overactive bladder, pain, dementia, cellulitis, lack of coordination, communication deficit, need for assistance with personal care, a healing fracture, and Parkinson's disease. The care plan required nursing staff to administer medications as ordered and monitor for side effects, with specific mention of monitoring for adverse effects of medication every shift. Despite these directives, the required weights were not obtained or documented as ordered, resulting in a failure to provide care in accordance with the physician's orders and the facility's policy.