Failure to Obtain and Document Ordered Weekly Weights
Penalty
Summary
Nursing staff failed to obtain and document weekly weights for a resident as ordered by the physician and recommended by the Registered Dietician (RD). The facility's policy required weekly weights for four weeks following admission, with more frequent monitoring if ordered by a physician. The resident, who had a history of acute CVA, aphasia, heart failure, subarachnoid hemorrhage, and myocardial infarction, was admitted with high sodium levels and was on two diuretics, making weight monitoring clinically significant. The RD specifically recommended weekly weights due to these factors, and a physician's order was in place for this monitoring. Despite these orders and recommendations, the medical record showed that only one weight was documented during the required period, with no evidence that weights were obtained or recorded for the subsequent two weeks. Interviews with facility staff, including the RD, Evening Supervisor, and DON, revealed that they were unaware the weights had not been obtained as ordered. The DON confirmed that it was facility expectation for nurses to follow all physician orders and to notify the DON and provider if unable to do so, but this process was not followed in this case.