Failure to Implement and Document Daily Weights for Resident with CHF
Penalty
Summary
A resident with a diagnosis of congestive heart failure (CHF) was admitted to the facility and had a care plan in place that included monitoring for signs and symptoms of CHF, such as weight gain. Hospital discharge documents included a physician's order for daily weights, with instructions to notify the provider if the resident's weight increased by more than 3 pounds in a day or 5 pounds in a week. However, there was no evidence that this order was accepted or declined by a facility provider upon admission. Further review showed that a physician's order for daily weights was not implemented until 17 days after admission. Documentation revealed that daily weights were not recorded on 11 out of 24 days during the review period. Interviews with the nurse practitioner and the Director of Nursing Services confirmed that there was no evidence the resident's weight was monitored daily as required by the care plan and physician's order.