Failure to Document Daily Weights and Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to obtain and document daily weights as ordered for a resident with congestive heart failure, and did not notify the physician or dietitian of significant weight gains as required by both physician orders and facility policy. The resident was admitted with an order for daily weights and specific parameters for physician notification if weight gain exceeded two pounds in a day or five pounds in a week. However, there were multiple days where weights were not recorded, and significant weight gains were documented without corresponding notifications to the physician or dietitian. Clinical records showed gaps in daily weight documentation for several days, and when a five-pound weight gain and a three-pound weight gain occurred, there was no evidence that the physician or dietitian was informed. The Director of Nursing confirmed the lack of documentation and failure to notify the physician of these significant weight changes. The facility's own policy required ongoing weight monitoring and prompt notification of significant changes, which was not followed in this case.