Failure to Notify Provider of Significant Weight Changes in Residents with CHF
Penalty
Summary
The facility failed to ensure that physicians were notified of significant weight changes for two residents with orders for daily weights related to congestive heart failure (CHF). For one resident, the treatment administration record showed a physician's order to notify the provider if there was a weight gain of more than 2 pounds in one day or 5 pounds in a week. Documentation revealed that on one occasion, the resident's weight increased by 11.8 pounds over two days, but there was no evidence that the provider was notified as required. Additionally, there were missing weight entries on certain days, and no documentation indicated that the provider was informed of these omissions. For the second resident, the record indicated a similar physician's order for daily weights with notification parameters for weight gain. However, weights were not obtained or were refused on multiple consecutive days, and again, there was no documentation that the provider was notified of the missed weights or refusals. Interviews with the Director of Nursing and the Nurse Practitioner confirmed that the provider was not notified of these findings as ordered.