Failure to Follow Physician Orders for Weekly Weight Monitoring
Penalty
Summary
The facility failed to implement physician orders for weekly weight monitoring for a resident who was cognitively intact and had diagnoses including neurogenic bladder, paraplegia, malnutrition, and depression. The physician order, active since late December, required weekly weights and vitals to be taken on bath day. The resident's care plan also identified a risk for nutrition and hydration problems, specifying that weights should be monitored per medical orders or facility policy. However, a review of the electronic medical and treatment administration records showed that the last documented weight for the resident was in December, with no further weights recorded through May. Interviews with facility staff confirmed that the responsibility for obtaining weights fell to the nurse on duty or could be delegated to a CNA, and that the process was tracked through the MAR, TAR, or by requests from dietary staff. The LPN confirmed no weights had been charted since December and was unsure of the reason. The DON also confirmed the lack of documented weights and emphasized the importance of following physician orders as part of the nurse's scope of practice and the resident's care plan. Facility policy required monitoring of residents' weights to maintain acceptable nutritional status.