Failure to Notify Physician and Clarify PRN Diuretic Order After Significant Weight Gain
Penalty
Summary
The facility failed to ensure that a physician was notified of a rapid and significant weight gain for a resident with multiple complex medical conditions, including congestive heart failure, diabetes, kidney failure, and a history of TIA and seizures. The resident experienced an 11.6-pound (9.2%) weight gain over a six-day period, as documented in the clinical record. Facility policy required nursing staff to confirm significant weight changes and notify the dietitian, with further interdisciplinary analysis of the resident's status. However, there was no evidence in the clinical record that the physician was notified of this significant weight gain, as confirmed by staff interviews and record review. Additionally, the facility failed to clarify a physician's order for Furosemide, which was prescribed as needed for shortness of breath or weight gain related to heart failure. The order did not specify how often the resident should be weighed or the exact criteria for administering the medication (such as the timeframe or amount of weight gain that would trigger administration). Staff confirmed that the order was not clarified, leaving ambiguity in care instructions for the resident.