Failure to Obtain Daily Weights as Ordered for Resident with Fluid Overload Risk
Penalty
Summary
The facility failed to obtain daily weights for a resident as ordered by the physician following a hospital discharge. The resident, who had a history of coronary artery disease, hypertension, peripheral vascular disease, respiratory failure, ischemic cardiomyopathy, and a prior coronary artery bypass graft, was readmitted from the hospital with instructions to be weighed daily and to notify the physician if there was a weight gain of three pounds or more in 48 hours. Despite these orders, daily weights were not recorded in the electronic health record for the remainder of September or throughout October. The care plan did not include interventions for daily weights or fluid restriction, and the October active orders did not reflect the need for daily weights. The resident experienced significant weight gain and worsening edema, ultimately requiring hospitalization for congestive heart failure exacerbation. Interviews with facility staff revealed that the protocol for monitoring fluid overload included daily weights, especially for residents with CHF or noted edema. However, the DON stated that daily weights were not obtained because the resident was not identified as having CHF in the facility records, and the APRN acknowledged that weights should have been obtained but were not. The lack of adherence to physician orders and facility protocols contributed to the failure to monitor the resident's fluid status appropriately.