Failure to Verify Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to ensure the accuracy of a weekly weight measurement for a resident with a history of Congestive Heart Failure (CHF) and on diuretic medication. The resident experienced a documented weight gain of 27.2 pounds in one week, but no immediate re-weigh was performed to confirm this significant change. Nursing staff involved in weighing the resident did not initiate a re-weigh, despite noticing the large discrepancy, and there was no documentation of a follow-up weight. The Director of Nursing stated that it was expected for any weight change greater than 5 pounds to be rechecked, especially for residents with CHF, but this protocol was not followed. Interviews with the Physician Assistant and Medical Director revealed that neither was informed of the resident's significant weight gain until after the fact. Both indicated that a re-weigh should have been conducted, and the Medical Director noted that the reported weight gain was likely inaccurate, as the resident did not exhibit related health symptoms and the weight was inconsistent with previous records. The failure to verify the resident's weight compromised the facility's ability to provide care in accordance with professional standards.