Failure to Obtain Daily Weights and Timely Follow-Up After Fall
Penalty
Summary
The facility failed to obtain daily weights as ordered for a resident with congestive heart failure (CHF), resulting in significant weight gain and hospitalization. The resident, who had a history of CHF, morbid obesity, respiratory failure, and other comorbidities, was observed to have gained over 60 pounds in one month. Despite a physician's order for daily weights, multiple days were missed without documentation of refusals or reasons for omission. Staff interviews confirmed that daily weights were not consistently obtained or recorded, and there was no evidence that the physician was notified of the significant weight gain as required by facility protocol. The Medication Administration Record did not reflect daily weights, and the facility lacked a policy for obtaining weights for CHF patients or for following physician orders related to weights. Additionally, the facility failed to ensure timely follow-up care after a resident experienced a fall resulting in a left clavicle fracture. The resident, who had multiple chronic conditions and was on hospice, fell while reaching for a TV remote and complained of shoulder pain. Although an X-ray was ordered, it was not completed until two days after the fall, and there was no documentation that staff followed up on the status of the X-ray or implemented a sling for immobilization until after the fracture was confirmed. Progress notes indicated the resident experienced pain and limited range of motion during this period, but interventions were delayed until the X-ray results were received. Interviews with facility staff, including the previous DON and nurse practitioner, confirmed that the delay in obtaining the X-ray and implementing appropriate interventions constituted a delay in care. The staff acknowledged that the X-ray should have been ordered and completed immediately, and that the resident should have received timely pain management and immobilization. The facility's failure to follow physician orders and ensure prompt follow-up after a significant change in condition contributed to the deficiencies identified in the care of both residents.