Failure to Obtain Daily Weights per Physician Orders for Residents with Heart Failure
Penalty
Summary
The facility failed to follow physician orders for obtaining daily weights for two residents diagnosed with heart failure. For one resident with severe cognitive impairment and congestive heart failure, the physician's order required daily weights to be taken in the morning before breakfast and after the first void, with instructions to notify the physician if certain weight gains occurred. However, there were three documented occasions when the resident was not weighed as ordered, and the Treatment Administration Record (TAR) indicated omissions with a chart code referencing nurses' notes. Upon review, there were no corresponding nurses' notes explaining the omissions on those dates. Similarly, another resident with heart failure and intact cognition had a physician's order for daily weights under the same protocol. There were six occasions when this resident was not weighed as ordered, with the TAR documenting chart codes for sleeping or referencing nurses' notes. Except for one note indicating the wheelchair scale was broken, there were no nurses' notes explaining the missed weights on the other dates. The Director of Nursing Services confirmed that daily weights should be taken as ordered, as the resident allows.