Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders and its own policy regarding weight monitoring for two residents. For one resident with chronic respiratory failure, tracheostomy, type II diabetes, and morbid obesity, the care plan required monthly weight monitoring due to increased risk for malnutrition. However, there was no recorded weight or documented refusal for one month, and the DON confirmed the absence of required documentation for that period. The resident was dependent on staff for activities of daily living and had intact cognition. For another resident with multiple respiratory and cardiac diagnoses, including obesity and chronic respiratory failure, the care plan also required monthly weight monitoring, and a physician order specified daily weights. A review of records showed that daily weights were missing on several specified dates, and the DON confirmed these weights were not obtained as ordered. The facility's policy required weights to be recorded at the time obtained and to follow physician orders for frequency, but this was not consistently done for these residents.