Failure to Follow Physician Order for Daily Weights in Resident with CHF
Penalty
Summary
The facility failed to follow a physician's order to obtain and document daily weights for a resident with diagnoses of congestive heart failure (CHF), hypotension, and atrial fibrillation. The resident was prescribed a diuretic (Lasix) to manage edema and required daily weights to monitor for signs of CHF, as ordered by the physician. Review of the resident's electronic medical record (EMR), including the Vitals tab, Medication Administration Record (MAR), Progress Notes, and Treatment Administration Record (TAR), revealed that staff did not measure or record the resident's weight on seven specific dates within a 27-day period. There was no documentation indicating that the resident refused to be weighed on those dates, nor was there evidence that the physician was notified about the missed weights. Interviews with nursing staff and administration confirmed that it was the nurse's responsibility to ensure daily weights were obtained and documented, and that refusals or issues should be reported to the physician and documented in the EMR. The facility's policy required physician orders to be followed as related to the care needs of individual residents. Despite these expectations and policies, the required daily weights were not consistently obtained or documented, and appropriate notifications were not made when weights were missed.