Failure to Notify Physician of Weight Gain and Inadequate Treatment of Non-Pressure Skin Alterations
Penalty
Summary
The facility failed to notify the physician of significant weight gain in a resident with congestive heart failure, despite clear discharge instructions from the hospital and facility policy requiring such notification. The resident experienced a weight increase of over 10 pounds within a week, as documented in the weight log, but there was no evidence that the physician was informed at any point. The Director of Nursing confirmed that the required notification did not occur. Additionally, the facility did not ensure that non-pressure skin alterations were treated according to physician orders for two residents. One resident with bilateral lower leg stasis dermatitis did not receive the recommended ammonia lactate application and daily ace wrap, as suggested by the wound consultant, due to the absence of corresponding physician orders. The Assistant Director of Nursing verified that the correct treatment was not provided as recommended. Another resident with multiple surgical incisions did not have dressings changed daily as ordered by the physician. Observations revealed that dressings had not been changed for three days, and the resident confirmed that only one dressing change was refused, with no staff offering to change the dressings on other days. Facility policy required that wound treatments be implemented as ordered, but this was not followed.