Failure to Document and Record Physician-Ordered Daily Weights
Penalty
Summary
The facility failed to ensure that physician orders for daily weights were completed and properly documented for a resident with multiple complex medical conditions, including acute respiratory failure, severe persistent asthma, type II diabetes, congestive heart failure, and a history of bariatric surgery. The resident had a physician order for daily weights due to their medical status and use of diuretics, and the care plan included monitoring and recording weights as ordered. However, review of the medical record showed that after the initial days following admission, no actual daily weights were recorded in the electronic medical record, and the last documented weight was several weeks prior to discharge. Staff were signing off on the Medication Administration Record (MAR) indicating that daily weights were completed, but no actual weight values were entered, except for one day marked as refused and one day left blank. Interviews with the Registered Dietitian and the DON confirmed that daily weights were not recorded as required by the physician's order, and that the facility's policy required weights to be documented in the resident's medical record. This failure had the potential to affect all residents in the facility.