Failure to Follow Physician Orders for Daily Weights and Fluid Restrictions
Penalty
Summary
Facility staff failed to follow physician's orders for a resident with a diagnosis of heart failure, specifically regarding daily weights and fluid restrictions. The resident had multiple orders for daily weights, with instructions to notify the practitioner of weight increases between 1-5 lbs. However, there were several documented instances where daily weights were not obtained, and significant weight gains were not reported to the practitioner as required. For example, an 8.6 lb. weight gain in one day and other increases of 6.7 lbs., 3.9 lbs., and 3.8 lbs. were not communicated to the practitioner. These omissions were confirmed by the DON during interviews. Additionally, the facility did not consistently implement or monitor the resident's fluid restriction orders. The resident was placed on various fluid restrictions, including 1000 ml and later 1440 ml per day, with specific allocations for dietary and nursing staff. Despite these orders, the resident's fluid intake regularly exceeded the prescribed limits, and there were days when fluid intake was not recorded at all. Observations and interviews revealed that staff were not always aware of the fluid restriction, did not consistently document fluids provided, and dietary staff did not record the amount of fluids given. The DON confirmed that the facility lacked a policy for implementing fluid restrictions and was unaware of how IV fluids were included in the daily total. The resident experienced multiple hospitalizations for conditions related to heart failure, fluid overload, and other complications during the period in question. Observations showed the resident receiving unmeasured fluids during meals and activities, and staff interviews indicated a lack of communication and understanding regarding the resident's fluid management needs. The facility was unable to provide additional information or documentation regarding the implementation of fluid restrictions prior to the survey exit.