Failure to Notify Physician of Rapid Weight Gain in CHF Resident
Penalty
Summary
The facility failed to notify a physician of a rapid weight gain in a resident with a diagnosis of Congestive Heart Failure (CHF), and did not seek clarification on physician orders regarding weight monitoring and notification parameters. The resident was admitted with CHF and had a hospital discharge weight of 188 lbs. Facility records show the resident's weight increased to 207 lbs. over a period of days, but there was no evidence that the primary physician was contacted about this significant weight gain or to clarify orders for weight monitoring and notification parameters, despite the absence of such parameters in the initial orders. Progress notes from the facility between admission and a cardiovascular appointment did not document any communication with the primary physician regarding the resident's weight changes or CHF management. The DON confirmed that staff did not clarify orders or notify the physician about the weight gain, and that there was no established protocol for staff to follow in such situations, aside from general best practice. The deficiency was identified through interview and document review, which revealed incomplete weight monitoring and lack of physician notification for a resident at risk due to CHF.