Failure to Implement Comprehensive Care Plan and Document Weights for Dialysis Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including end stage renal disease, heart failure, and dependence on dialysis. The resident required total assistance with activities of daily living and had severe cognitive impairment. Although the care plan identified the need to monitor for fluid overload and included interventions such as monitoring and documenting weights, the facility did not ensure that weights were consistently documented as ordered by the physician. Specifically, there was no documentation of the resident's weight on a scheduled date, and this omission was confirmed through review of the medical administration record, treatment administration record, and progress notes. Interviews with staff revealed that weights were typically obtained by aides and then reported to the nurse for documentation, but in this instance, the required documentation was missing. The DON and Administrator acknowledged that weights were important for tracking the resident's progress and care, and that failure to document weights could result in a lack of awareness of the resident's condition. The facility's policy emphasized person-centered care and monitoring of key indicators such as unintended weight loss, but the failure to document weights as required represented a lapse in following both physician orders and facility policy.