Failure to Implement Physician Orders for Weights and Vital Signs
Penalty
Summary
The facility failed to implement physician orders for four residents, as evidenced by a review of facility policy, clinical records, and staff interviews. For three residents with diagnoses including heart failure, kidney disease, and diabetes, physician orders required daily weights and notification to the physician if specific weight gains occurred. However, the Medication Administration Records (MAR) for these residents showed multiple days where weights were not documented as obtained. Additionally, for a resident with high blood pressure, staff were ordered to check the heart rate prior to administering a blood pressure medication and to withhold the medication if the heart rate was below a certain threshold. The MAR indicated that the medication was administered on several occasions without documented evidence that the heart rate was assessed beforehand. The Director of Nursing confirmed in interviews that there was no documented evidence that the required daily weights or heart rates were obtained according to physician orders. The facility's policy on medication administration required staff to follow written physician orders and document vital signs as indicated, but this was not consistently done for the residents in question.