Failure to Verify Accuracy of Physician-Ordered Weights for Resident with CHF
Penalty
Summary
The facility failed to verify the accuracy of physician-ordered weights for a resident with congestive heart failure, resulting in inaccurate documentation of significant weight changes. The resident, who had multiple chronic conditions including CHF, COPD, and dementia, was at nutritional risk and had a care plan that included regular weight monitoring due to a history of weight fluctuations, fluid retention, and recent significant weight loss. Despite physician orders for weekly and monthly weights, and care plan interventions to weigh per policy, the facility did not ensure that weights were rechecked when large fluctuations were recorded. Review of the resident's medical record showed several instances of dramatic weight changes, such as a 20-pound loss in four days, without a reweigh being performed to confirm accuracy. Staff interviews revealed that nurse aides obtained weights and reported them to the unit manager, who entered them into the electronic medical record without always checking for significant changes. The unit manager acknowledged not directing staff to perform reweighs when large discrepancies occurred, contrary to facility policy. The nurse practitioner and physician both stated that significant weight changes should trigger a reweigh to ensure accurate data for clinical decision-making. Further interviews confirmed that nurse aides relied on instructions from nursing staff to perform reweighs and would not do so independently. The physician noted that some documented weights were implausible and had not been reported as changes in condition. The DON stated that staff were expected to review and compare weights, and to obtain a reweigh if there was a significant increase or decrease, but this process was not followed. As a result, inaccurate weights were documented, and significant changes were not verified or reported as required.